Guidelines in the intensive care unit

Improving quality of withdrawal of life-sustaining measures in organ donation: a framework and implementation toolkit

BACKGROUND

Donation after circulatory determination of death (DCD) is responsible for the largest increase in deceased donation over the past decade. When the Canadian DCD guideline was published in 2006, it included recommendations to create standard policies and procedures for withdrawal of life-sustaining measures (WLSM) as well as quality assurance frameworks for this practice. In 2016, the Canadian Critical Care Society produced a guideline for WLSM that requires modifications to facilitate implementation when DCD is part of the end-of-life care plan.

METHODS

A pan-Canadian multidisciplinary collaborative was convened to examine the existing guideline framework and to create tools to put the existing guideline into practice in centres that practice DCD.

RESULTS

A set of guiding principles for implementation of the guideline in DCD practice were produced using an iterative, consensus-based approach followed by development of four implementation tools and three quality assurance and audit tools.

CONCLUSIONS

The tools developed will aid DCD centres in fulsomely adapting the Canadian Critical Care Society Withdrawal of Life-Sustaining Measures guideline.

A Qualitative Study Exploring Factors Associated with Provider Adherence to Severe Pediatric Traumatic Brain Injury Guidelines

Despite demonstrated improvement in patient outcomes with use of the Pediatric Traumatic Brain Injury (TBI) Guidelines (Guidelines), there are differential rates of adherence. Provider perspectives on barriers and facilitators to adherence have not been elucidated. This study aimed to identify and explore in depth the provider perspective on factors associated with adherence to the Guidelines using 19 focus groups with nurses and physicians who provided acute management for pediatric patients with TBI at five university-affiliated Level 1 trauma centers. Data were examined using deductive and inductive content analysis. Results indicated that three inter-related domains were associated with clinical adherence: 1) perceived guideline credibility and applicability to individual patients, 2) implementation, dissemination, and enforcement strategies, and 3) provider culture, communication styles, and attitudes towards protocols. Specifically, Guideline usefulness was determined by the perceived relevance to the individual patient given age, injury etiology, and severity and the strength of the evidence. Institutional methods to formally endorse, codify, and implement the Guidelines into the local culture were important. Providers wanted local protocols developed using interdisciplinary consensus. Finally, a culture of collaboration, including consistent, respectful communication and interdisciplinary cooperation, facilitated adherence. Provider training and experience, as well as attitudes towards other standardized care protocols, mirror the use and attitudes towards the Guidelines. Adherence was determined by the interaction of each of these guideline, institutional, and provider factors acting in concert. Incorporating provider perspectives on barriers and facilitators to adherence into hospital and team protocols is an important step toward improving adherence and ultimately patient outcomes.

Noninvasive ventilation initiation in clinical practice: A six-year prospective, observational study

BACKGROUND

Despite evidence supporting the role of noninvasive ventilation (NIV) in diverse populations, few publications describe how NIV is used in clinical practice.

OBJECTIVE

To describe NIV initiation in a teaching hospital that has a guideline, and to characterize temporal changes in NIV initiation over time.

METHODS

A prospective, observational study of continuous positive airway pressure ventilation (CPAP) or bilevel NIV initiation from January 2000 to December 2005 was conducted. Registered respiratory therapists completed a one-page data collection form at NIV initiation.

RESULTS

Over a six-year period, NIV was initiated in 623 unique patients (531 bilevel NIV, 92 CPAP). Compared with bilevel NIV, CPAP was initiated more often using a nasal interface, with a machine owned by the patient, and for chronic conditions, especially obstructive sleep apnea. Whereas CPAP was frequently initiated and continued on the wards, bilevel NIV was most frequently initiated and continued in the emergency department, intensive care unit and the coronary care unit. Patients initiated on bilevel NIV were more likely to be female (OR 1.8, 95% CI 1.08 to 2.85; P=0.02) and to have an acute indication compared with CPAP initiations (OR 7.5, 95% CI 1.61 to 34.41; P=0.01). Bilevel NIV was initiated more often in the emergency department than in the intensive care unit (OR 5.8, 95% CI 0.89 to 38.17; P=0.07). Bilevel NIV initiation increased from 2000 to 2005.

CONCLUSIONS

The present study illustrates how NIV is used in clinical practice and confirms that NIV initiation has increased over time.

Pay for performance in the intensive care unit--opportunity or threat?

OBJECTIVE

Ongoing evidence of poor-quality healthcare has stimulated the development of provider reimbursement schemes linked to the delivery of high-quality care. Our objective was to describe these programs and their potential implementation in intensive care units (ICUs).

SOURCES

MEDLINE (2000-May, 2008) and personal files.

STUDY SELECTION

We selected empirical studies, narrative and systematic reviews, and commentaries addressing pay-for-performance programs.

DATA EXTRACTION

Using a narrative review format, we discuss the definition of pay-for-performance, describe current implementations, suggest challenges of applying these programs to the ICU setting, and discuss alternative quality improvement programs.

DATA SYNTHESIS

The ICU will likely become a target for pay-for-performance plans, considering the high cost of care, development of ICU quality-of-care measures, and interest from healthcare regulators and funders. Existing plans applied outside the ICU have varied in the amount of financial incentive and targeted provider and quality measures. Evaluations are sparse. Implementation challenges specific to the ICU include selecting evidence-based and feasible quality of care measures, motivating the entire interdisciplinary team, integrating multifaceted behavior change strategies, and developing informatics infrastructure for timely audit and feedback. Other incentive-based alternatives to improve ICU quality of care include a "centers of excellence" approach (referral of patients to centers with excellent outcomes), public reporting of ICU outcomes, and payments to hospitals for participating in quality improvement programs.

CONCLUSIONS

Participation in pay-for-performance programs is a potential opportunity for intensivists and ICU teams to improve outcomes for their patients in partnership with regulatory agencies and healthcare funders. Because many aspects of optimal design of these programs in ICUs are unknown, robust evaluations of their effect on healthcare quality should be integrated into any implementations.

Value choices and considerations when limiting intensive care treatment: a qualitative study

BACKGROUND

To shed light on the values and considerations that affect the decision-making processes and the decisions to limit intensive care treatment.

METHOD

Qualitative methodology with participant observation and in-depth interviews, with an emphasis on eliciting the underlying rationale of the clinicians' actions and choices when limiting treatment.

RESULTS

Informants perceived over-treatment in intensive care medicine as a dilemma. One explanation was that the decision-making base was somewhat uncertain, complex and difficult. The informants claimed that those responsible for taking decisions from the admitting ward prolonged futile treatment because they may bear guilt or responsibility for something that had gone wrong during the course of treatment. The assessments of the patient's situation made by physicians from the admitting ward were often more organ-oriented and the expectations were less realistic than those of clinicians in the intensive care unit who frequently had a more balanced and overall perspective. Aspects such as the personality and the speciality of those involved, the culture of the unit and the degree of interdisciplinary cooperation were important issues in the decision-making processes.

CONCLUSION

Under-communicated considerations jeopardise the principle of equal treatment. If intensive care patients are to be ensured equal treatment, strategies for interdisciplinary, transparent and appropriate decision-making processes must be developed in which open and hidden values are rendered visible, power structures disclosed, employees respected and the various perspectives of the treatment given their legitimate place.

Dissemination of the Canadian clinical practice guidelines for nutrition support: results of a cluster randomized controlled trial

OBJECTIVE

To compare the effectiveness of active to passive dissemination of the Canadian clinical practice guidelines (CPGs) for nutrition support for the mechanically ventilated critically ill adult patient.

DESIGN

A cluster-randomized trial with a cross-sectional outcome assessment at baseline and 12 months later.

SETTING

Intensive care units in Canada.

PATIENTS

Consecutive samples of mechanically ventilated patients at each time period.

INTERVENTIONS

In the active group, we provided multifaceted educational interventions including Web-based tools to dietitians. In the passive group, we mailed the CPGs to dietitians.

MEASUREMENTS AND MAIN RESULTS

The primary end point of this study was nutritional adequacy of enteral nutrition; secondary end points measured were compliance with the CPGs, glycemic control, duration of stay in intensive care unit and hospital, and 28-day mortality. Fifty-eight sites were randomized. At baseline and follow-up, 623 and 612 patients were evaluated. Both groups were well matched in site and patient characteristics. Changes in enteral nutrition adequacy between the active and passive arms were similar (8.0% vs. 6.2 %, p = .54). Median time spent in the target glucose range increased 10.1% in the active compared with 1.8% in the passive group (p = .001). In the subgroup of medical patients, enteral nutrition adequacy improved more in the active arm compared with the passive group (by 8.1%, p = .04), whereas no such differences were observed in surgical patients. When groups were combined, during the year of dissemination activities, there was an increase in enteral nutrition adequacy (from 43% to 50%, p < .001), an increase in the use of feeding protocols (from 64% to 76%, p = .03), and a decrease in patients on parenteral nutrition (from 26% to 21%, p = .04). There were no differences in clinical outcomes between groups or across time periods.

CONCLUSIONS

Although active dissemination of the CPGs did improve glycemic control, it did not change other nutrition practices or patient outcomes except in a subgroup of medical patients. Overall, dissemination of the CPGs improved other important nutrition support practices but was not associated with improvements in clinical outcomes.

The effects of a treatment protocol for cardiac surgical patients with excessive blood loss on clinical outcomes

BACKGROUND AND OBJECTIVES

Excessive blood loss (EBL) is a common complication of cardiac surgery that is associated with adverse events. The objective of this before/after study was to determine whether the implementation of a protocol for management of cardiac surgical patients with EBL was associated with improved clinical outcomes.

MATERIALS AND METHODS

In November 2002, a protocol for prompt identification and aggressive management of cardiac surgical patients with EBL was implemented at our institution. The independent relationship between protocol implementation and adverse outcomes was measured by comparing the outcomes of patients who received > or = 4 RBC (red blood cell) units within 1 day of surgery and were operated on before protocol implementation (2000-02) with those operated on after protocol implementation (2003-05), using multivariable logistic regression analysis to control for the effects of confounders. The primary outcome was a composite of adverse events that included death, renal failure, stroke, and sepsis. Bootstrapping was used to confirm the validity of the results.

RESULTS

Of the 11,314 patients who underwent surgery during the study period, 1875 (16.6%) received > or = 4 RBC units within 1 day of surgery, with 958 and 917 in the pre- and postprotocol periods, respectively. The composite adverse outcome occurred in 164 (17.1%) patients in the preprotocol period and 115 (12.5%) patients in the postprotocol period (P = 0.005). Protocol implementation was independently associated with reduced odds of the composite adverse outcome (odds ratio 0.67; 95% confidence interval 0.50, 0.91; P = 0.01). This estimate was stable in bootstrap sampling.

CONCLUSION

Implementation of a protocol to manage EBL in cardiac surgery was independently associated with improved outcomes.

Protocol for bedside laparotomy in trauma and emergency general surgery: a low return to the operating room

Bedside laparotomy (BSL) was introduced as a heroic procedure in trauma patients too unstable for safe transport to the operating room (OR). We hypothesize a BSL protocol would maintain patient safety while reducing OR use. Patients were prospectively entered into a BSL protocol from July 2002 to June 2003 and retrospectively reviewed. Protocol indications for BSL were abdominal compartment syndrome, decompensation due to hemorrhage, washout/closure, and sepsis in a patient too unstable for safe transport to the OR. Primary outcomes were mortality, emergent return to OR, and primary fascial closure (PFC). Trauma operating room charges and OR time were analyzed. One hundred thirty-three BSL were performed on 60 patients with an overall mortality of 23.3 per cent (14/60). There was an average of 2.2 BSL per patient (range 1-8). Indications for BSL were 1) explore/washout (n = 100, 75.2%), 2) decompression (n = 14, 10.5%), 3) infection/abscess (n = 12, 9.0%), 4) hemorrhage (n = 7, 5.3%). Five of 133 BSL (5.8%) were emergently returned to the OR because of perforation or compromised bowel. Trauma OR charges were dollar 5,300 per cases with 2.12 hours per cases. The protocol standardized the conduct of BSL procedure to allow for a low return to OR rate of 5.8 per cent and had an overall in-hospital mortality rate of 23.3 per cent. Primary fascial closure of the abdomen had a significantly reduced hospital stay. BSL allowed trauma OR charges of dollar 5,300 per cases with 2.12 hours per cases savings.

Sepsis strategies: an ICU package?

--Mortality of patients with severe sepsis remains at unacceptable levels and recent new strategies are not being widely embraced. --Five strategies are discussed within this article [low tidal volumes in acute lung injury/acute respiratory distress syndrome, early goal-directed therapy, drotrecogin alfa (activated), moderate dose corticosteroids and tight control of blood glucose]. --The critical care nurse plays a leading role in the detection, monitoring and treatment of patients with severe sepsis. --The role of the critical care nurse within the multidisciplinary team is explored. --Education, combination of strategies and the use of protocols are discussed.