1
|
Yarnell CJ. Two Consecutive Weeks Are No Better Than One at a Time: Targeting Optimal Intensivist Scheduling. Crit Care Med 2024; 52:1476-1478. [PMID: 39145703 DOI: 10.1097/ccm.0000000000006344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Affiliation(s)
- Christopher J Yarnell
- Department of Critical Care Medicine, Scarborough Health Network, Toronto, ON, Canada
- Scarborough Health Network Research Institute, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
2
|
Largent EA, Joffe S, Dickert NW, Morain SR. The ethical value of consulting community members in non-emergency trials conducted with waivers of informed consent for research. Clin Trials 2024:17407745241259360. [PMID: 38916109 DOI: 10.1177/17407745241259360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
There is growing interest in using embedded research methods, particularly pragmatic clinical trials, to address well-known evidentiary shortcomings afflicting the health care system. Reviews of pragmatic clinical trials published between 2014 and 2019 found that 8.8% were conducted with waivers of informed consent; furthermore, the number of trials where consent is not obtained is increasing with time. From a regulatory perspective, waivers of informed consent are permissible when certain conditions are met, including that the study involves no more than minimal risk, that it could not practicably be carried out without a waiver, and that waiving consent does not violate participants' rights and welfare. Nevertheless, when research is conducted with a waiver of consent, several ethical challenges arise. We must consider how to: address empirical evidence showing that patients and members of the public generally prefer prospective consent, demonstrate respect for persons using tools other than consent, promote public trust and investigator integrity, and ensure an adequate level of participant protections. In this article, we use examples drawn from real pragmatic clinical trials to argue that prospective consultation with representatives of the target study population can address, or at least mitigate, many of the ethical challenges posed by waivers of informed consent. We also consider what consultation might involve to illustrate its feasibility and address potential objections.
Collapse
Affiliation(s)
- Emily A Largent
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephanie R Morain
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
3
|
Krishna B. Day and Time of Admission to ICU Affects Patient Outcome: An Illogical Belief? Indian J Crit Care Med 2024; 28:414-415. [PMID: 38738196 PMCID: PMC11080100 DOI: 10.5005/jp-journals-10071-24721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
How to cite this article: Krishna B. Day and Time of Admission to ICU Affects Patient Outcome: An Illogical Belief? Indian J Crit Care Med 2024;28(5):414-415.
Collapse
Affiliation(s)
- Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, Karnataka, India
| |
Collapse
|
4
|
Debay A, Shah P, Lodha A, Shivananda S, Redpath S, Seshia M, Dorling J, Lapointe A, Canning R, Strueby L, Beltempo M. Association of 24-Hour In-house Neonatologist Coverage with Outcomes of Extremely Preterm Infants. Am J Perinatol 2024; 41:747-755. [PMID: 35170012 DOI: 10.1055/a-1772-4637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to assess if 24-hour in-house neonatologist (NN) coverage is associated with delivery room (DR) resuscitation/stabilization and outcomes among inborn infants <29 weeks' gestational age (GA). STUDY DESIGN Survey-linked cohort study of 2,476 inborn infants of 23 to 28 weeks' gestation, admitted between 2014 and 2015 to Canadian Neonatal Network Level-3 neonatal intensive care units (NICUs) with a maternity unit. Exposures were classified using survey responses based on the most senior provider offering 24-hour in-house coverage: NN, fellow, and no NN/fellow. Primary outcome was death and/or major morbidity (bronchopulmonary dysplasia, severe neurological injury, late-onset sepsis, necrotizing enterocolitis, and retinopathy of prematurity). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders. RESULTS Among the 28 participating NICUs, most senior providers ensuring 24-hour in-house coverage were NN (32%, 9/28), fellows (39%, 11/28), and no NN/fellow (29%, 8/28). No NN/fellow coverage and 24-hour fellow coverage were associated with higher odds of infants receiving DR chest compressions/epinephrine compared with 24-hour NN coverage (adjusted odds ratio [aOR] = 4.72, 95% confidence interval [CI]: 2.12-10.6 and aOR = 3.33, 95% CI: 1.44-7.70, respectively). Rates of mortality/major morbidity did not differ significantly among the three groups: NN, 63% (249/395 infants); fellow, 64% (1092/1700 infants); no NN/fellow, 70% (266/381 infants). CONCLUSION 24-hour in-house NN coverage was associated with lower rates of DR chest compressions/epinephrine. There was no difference in neonatal outcomes based on type of coverage; however, further studies are needed as ecological fallacy cannot be ruled out. KEY POINTS · Lower rates of DR cardiopulmonary resuscitation with 24h in-house NN coverage. · The type of 24h in-house coverage was not associated with mortality and/or major morbidity.. · High-volume centers more often have 24h in-house neonatal fellow coverage.
Collapse
Affiliation(s)
- Anthony Debay
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Prakesh Shah
- Departement of Pediatrics, Toronto University, Toronto, Ontario, Canada
| | - Abhay Lodha
- Departement of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sandesh Shivananda
- Departement of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie Redpath
- Departement of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Seshia
- Departement of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jon Dorling
- Departement of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anie Lapointe
- Departement of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Rody Canning
- Departement of Pediatrics, Moncton Hospital, Moncton, Alberta, Canada
| | - Lannae Strueby
- Departement of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
5
|
Armaignac DL, Ramamoorthy V, DuBouchet EM, Williams LM, Kushch NA, Gidel L, Badawi O. Descriptive Comparison of Two Models of Tele-Critical Care Delivery in a Large Multi-Hospital Health Care System. Telemed J E Health 2023; 29:1465-1475. [PMID: 36827094 DOI: 10.1089/tmj.2022.0415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Introduction: The Society of Critical Care Medicine Tele-Critical Care (TCC) Committee has identified the need for rigorous comparative research of different TCC delivery models to support the development of best practices for staffing, application, and approaches to workflow. Our objective was to describe and compare outcomes between two TCC delivery models, TCC with 24/7 Bedside Intensivist (BI) compared with TCC with Private Daytime Attending Intensivist (PI) in relation to intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), cost, and complications across the spectrum of routine ICU standards of care. Methods: Observational cohort study at large health care system in 12 ICUs and included patients, ≥18, with Acute Physiology and Chronic Health Evaluation (APACHE) IVa scores and predictions (October 2016-June 2019). Results: Of the 19,519 ICU patients, 71.7% (n = 13,993) received TCC with 24/7 BI while 28.3% (n = 5,526) received TCC with PI. ICU and Hospital mortality (4.8% vs. 3.1%, p < 0.0001; 12.6% vs. 8.1%, p < 0.001); and ICU and Hospital LOS (3.2 vs. 2.4 days, p < 0.001; 9.8 vs. 7.2 days, p < 0.001) were significantly higher among 24/7 BI compared with PI. The APACHE observed/expected ratios (odds ratio [OR]; 95% confidence interval [CI]) for ICU mortality (0.62; 0.58-0.67) vs. (0.53; 0.46-0.61) and Hospital mortality (0.95; 0.57-1.48) vs. (0.77; 0.70-0.84) were significantly different for 24/7 BI compared with PI. Multivariate mixed models that adjusted for confounders demonstrated significantly greater odds of (OR; 95% CI) ICU mortality (1.58; 1.28-1.93), Hospital mortality (1.52; 1.33-1.73), complications (1.55; 1.18-2.04), ICU LOS [3.14 vs. 2.59 (1.25; 1.19-1.51)], and Hospital LOS [9.05 vs. 7.31 (1.23; 1.21-1.25)] among 24/7 BI when compared with PI. Sensitivity analyses adjusting for ICU admission within 24 h of hospital admission, receiving active ICU treatments, nighttime admission, sepsis, and highest third acute physiology score indicated significantly higher odds for 24/7 BI compared with PI. Conclusion: Our comparison demonstrated that TCC delivery model with PI provided high-quality care with significant positive effects on outcomes. This suggests that TCC delivery models have broad-ranging applicability and benefits in routine critical care, thus necessitating progressive research in this direction.
Collapse
Affiliation(s)
- Donna Lee Armaignac
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
| | | | - Eduardo Martinez DuBouchet
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
- Wertheim School of Medicine, Florida International University, Miami, Florida, USA
| | - Lisa-Mae Williams
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
- Wertheim School of Medicine, Florida International University, Miami, Florida, USA
| | | | - Louis Gidel
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
| | - Omar Badawi
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| |
Collapse
|
6
|
Lee J, Ahn S, Henning MA, van de Ridder JMM, Rajput V. Micromanagement in clinical supervision: a scoping review. BMC MEDICAL EDUCATION 2023; 23:563. [PMID: 37559079 PMCID: PMC10410949 DOI: 10.1186/s12909-023-04543-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 07/27/2023] [Indexed: 08/11/2023]
Abstract
Micromanagement in clinical supervision in health professions education generally refers to supervision characterized by unproductive excessive control and attention to detail. It can affect autonomy, competence, well-being of learners, teamwork, and ultimately patient care. Despite its potential negative impact on learners and patients, no comprehensive review of this phenomenon has been conducted. This scoping review aims to explore the breadth of extant literature concerning micromanagement in clinical supervision in health professions education and map the body of research on the topic. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review (PRISMA-ScR). We searched eight databases, and the final review and analysis comprised 12 articles that examined micromanagement in clinical supervision across health professions education. Micromanagement was conceptualized as ineffective supervisory practices such as undue scrutiny, excessive control, domination, and ineffectual leadership. Conversely, alternatives to micromanagement included entrusting or granting autonomy, coaching for independent practice, and providing effective supervision and leadership. Overall, micromanagement was attributed to individual behavioral and personality factors, such as distrust, perfectionism, self-conviction, and low self-esteem. The consequences of micromanagement included inadequacies in professional development and well-being of trainees and patient care, and organizational dysfunction. Suggested solutions included entrusting or empowering trainees with encouragement and clear communication, open communication efforts by trainees, organizational management for quality supervision, and faculty's valuing both clinical and educational goals. Current literature on micromanagement-in the context of clinical supervision in health professions education-was found to be sparse, implying a need for more rigorous research and discourse on this understudied area. The findings can be used to recognize, solve, and prevent the prevalent, and often unrecognized, phenomena of micromanagement, which may improve clinical supervision, the professional development of trainees and faculty, organizational management, and ultimately patient care.
Collapse
Affiliation(s)
- Jihyun Lee
- Department of Dental Education & Dental Research Institute, School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
| | - Solmoe Ahn
- Dental Research Institute, School of Dentistry, Seoul National University, Seoul, South Korea
| | - Marcus A Henning
- Centre for Medical and Health Sciences Education, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | | | - Vijay Rajput
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Florida, USA
| |
Collapse
|
7
|
Flynn BC. Anesthesiology Critical Care: Current State and Future Directions. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00248-3. [PMID: 37164803 DOI: 10.1053/j.jvca.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/28/2023] [Accepted: 04/07/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Brigid C Flynn
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS.
| |
Collapse
|
8
|
Morita K, Matsui H, Ono S, Fushimi K, Yasunaga H. Association between better night-shift nurse staffing and surgical outcomes: A retrospective cohort study using a nationwide inpatient database in Japan. J Nurs Scholarsh 2023; 55:494-505. [PMID: 36345776 DOI: 10.1111/jnu.12845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/14/2022] [Accepted: 10/24/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Although many studies have investigated the relationship between patient outcomes and the level of nurse staffing, little is known about the association between increased night-shift nurse staffing and patient outcomes. In the Japanese universal health insurance system, a new scheme of additional financial incentives for acute care hospitals was launched in 2012 to increase the number of nurses during the night shift in general wards. The objective of this study was to investigate whether an additional financial incentive to increase night-shift nurse staffing in general wards was associated with better patient outcomes. DESIGN Adoption of the above-mentioned scheme of additional financial incentives was used as a natural experiment, and the difference-in-differences method was conducted to evaluate the effect of the scheme. The study was performed using a nationwide inpatient database and hospital information in Japan. METHODS To conduct a difference-in-differences analysis, first, hospitals with and without increased night-shift nurse staffing were matched using propensity score matching. A patient-level difference-in-differences analysis was then conducted. The intervention group comprised the hospitals that adopted the new scheme of additional financial incentives. The outcome measures were in-hospital mortality, failure to rescue, and length of hospital stay. RESULTS Subjects were 403,971 adult patients who underwent planned major surgeries in Japanese acute care hospitals from April 2012 to March 2018. The adjusted difference-in-differences estimates were not significant for in-hospital mortality (odds ratio: 0.83; 95% confidence interval: 0.68 to 1.01; p = 0.07) or failure to rescue (odds ratio: 0.92; 95% confidence interval: 0.73 to 1.14; p = 0.44). The adjusted difference-in-differences estimate for length of hospital stay was significant (percent change: -3.2%; 95% confidence interval: -6.1 to -0.3%; p = 0.029), indicating that the adoption of the scheme was associated with a decreased length of hospital stay. CONCLUSIONS Increased night-shift nurse staffing was not associated with a decrease in in-hospital mortality or failure to rescue, but it was associated with a reduction in the length of hospital stay. It may be necessary to consider changes in policy content to make the policy more effective. The findings of this study are potentially useful for medical policymakers considering nurse staffing to decrease the length of stay, which may decrease costs. CLINICAL RELEVANCE This study showed that increased night-shift nurse staffing was not associated with a decrease in in-hospital mortality or failure to rescue, but it was associated with a reduction in the length of hospital stay. The examination of the effectiveness of increasing nurse staffing during a specific shift in acute care hospitals is potentially useful for health policymakers worldwide in their considerations of future nurse staffing policies.
Collapse
Affiliation(s)
- Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
9
|
Examination of Impact of After-Hours Admissions on Hospital Resource Use, Patient Outcomes, and Costs. Crit Care Res Pract 2022; 2022:4815734. [DOI: 10.1155/2022/4815734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 11/25/2022] Open
Abstract
Background. Nighttime and weekends in hospital and intensive care unit (ICU) contexts are thought to present a greater risk for adverse events than daytime admissions. Although some studies exist comparing admission time with patient outcomes, the results are contradictory. No studies currently exist comparing costs with the time of admission. We investigated the differences in-hospital mortality, ICU length of stay, ICU mortality, and cost between daytime and nighttime admissions. Methods. All adult patients (≥18 years of age) admitted to a large academic medical-surgical ICU between 2011 and 2015 were included. Admission cohorts were defined as daytime (8:00–16:59) or nighttime (17:00–07:59). Student’s t-tests and chi-squared tests were used to test for associations between days spent in the ICU, days on mechanical ventilation, comorbidities, diagnoses, and cohort membership. Regression analysis was used to test for associations between patient and hospitalization characteristics and in-hospital mortality and total ICU costs. Results. The majority of admissions occurred during nighttime hours (69.5%) with no difference in the overall Elixhauser comorbidity score between groups (
). Overall ICU length of stay was 7.96 days for daytime admissions compared to 7.07 days (
) for patients admitted during nighttime hours. Overall mortality was significantly higher in daytime admissions (22.5% vs 20.6,
); however, ICU mortality was not different. The average MODS was 2.9 with those admitted during the daytime having a significantly higher MODS (3.0,
). Total ICU cost was significantly higher for daytime admissions (
). Adjusted ICU mortality was similar in both groups despite an increased rate of adverse events for nighttime admissions. Daytime admissions were associated with increased cost. There was no difference in all hospital total cost or all hospital direct cost between groups. These findings are likely due to the higher severity of illness in daytime admissions. Conclusion. Daytime admissions were associated with a higher severity of illness, mortality rate, and ICU cost. To further account for the effect of staffing differences during off-hours, it may be beneficial to compare weekday and weeknight admission times with associated mortality rates.
Collapse
|
10
|
Been JV, Smith GC, Cooper SA, Pell JP, Mackay DF. Time of birth and additional support need at school age: national cohort study of 865,409 children. J Perinatol 2022; 43:523-525. [PMID: 36209232 DOI: 10.1038/s41372-022-01524-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Jasper V Been
- Division of Neonatology, Department of Paediatrics, Department of Obstetrics and Gynaecology, and Department of Public Health, Erasmus MC Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - Gordon C Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK
| | - Sally-Ann Cooper
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jill P Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Daniel F Mackay
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| |
Collapse
|
11
|
Agarwal A, Chen JT, Coopersmith CM, Denson JL, Dickert NW, Ferrante LE, Gershengorn HB, Gosine AD, Hayward BJ, Kaur N, Khan A, Lamberton C, Landsittel D, Lyons PG, Mikkelsen ME, Nadig NR, Pietropaoli AP, Poole BR, Viglianti EM, Sevransky JE. SWEAT ICU-An Observational Study of Physician Workload and the Association of Physician Outcomes in Academic ICUs. Crit Care Explor 2022; 4:e0774. [PMID: 36259061 PMCID: PMC9575792 DOI: 10.1097/cce.0000000000000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The optimal staffing model for physicians in the ICU is unknown. Patient-to-intensivist ratios may offer a simple measure of workload and be associated with patient mortality and physician burnout. To evaluate the association of physician workload, as measured by the patient-to-intensivist ratio, with physician burnout and patient mortality. DESIGN Cross-sectional observational study. SETTING Fourteen academic centers in the United States from August 2020 to July 2021. SUBJECTS We enrolled ICU physicians and collected data on adult ICU patients under the physician's care on the single physician-selected study day for each physician. MEASUREMENTS and MAIN RESULTS The primary exposure was workload (self-reported number of patients' physician was responsible for) modeled as high (>14 patients) and low (≤14 patients). The primary outcome was burnout, measured by the Well-Being Index. The secondary outcome measure was 28-day patient mortality. We calculated odds ratio for burnout and patient outcomes using a multivariable logistic regression model and a binomial mixed effects model, respectively. We enrolled 122 physicians from 62 ICUs. The median patient-to-intensivist ratio was 12 (interquartile range, 10-14), and the overall prevalence of burnout was 26.4% (n = 32). Intensivist workload was not independently associated with burnout (adjusted odds ratio, 0.74; 95% CI, 0.24-2.23). Of 1,322 patients, 679 (52%) were discharged alive from the hospital, 257 (19%) remained hospitalized, and 347 (26%) were deceased by day 28; 28-day outcomes were unknown for 39 of patients (3%). Intensivist workload was not independently associated with 28-day patient mortality (adjusted odds ratio, 1.33; 95% CI, 0.92-1.91). CONCLUSIONS In our cohort, approximately one in four physicians experienced burnout on the study day. There was no relationship be- tween workload as measured by patient-to-intensivist ratio and burnout. Factors other than the number of patients may be important drivers of burnout among ICU physicians.
Collapse
Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Jen-Ting Chen
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Craig M Coopersmith
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Joshua L Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Neal W Dickert
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Hayley B Gershengorn
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Adhiraj D Gosine
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Bradley J Hayward
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Navneet Kaur
- Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Akram Khan
- Division of Pulmonary Critical Care, Oregon Health and Science University, Portland, OR
| | - Courtney Lamberton
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Douglas Landsittel
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN
| | - Patrick G Lyons
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Mark E Mikkelsen
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Nandita R Nadig
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Anthony P Pietropaoli
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Brian R Poole
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Elizabeth M Viglianti
- Division Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| |
Collapse
|
12
|
Bakhru RN, Propert KJ, Kawut SM, Schweickert WD. A Survey of Implementation of ABCDE Protocols. J Intensive Care Med 2022; 38:86-94. [PMID: 35731642 DOI: 10.1177/08850666221109157] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), delirium assessment/management, early mobility have been termed the ABCDE bundle. The ABCDE bundle has been proven to improve patient outcomes. However, there is often a long gap in dissemination and implementation of evidence-based medicine. OBJECTIVES To determine the prevalent implementation of and determinants for ABCDE protocol adoption in Pennsylvania. METHODS We developed a survey of ABCDE bundle protocols. We surveyed factors around implementation including written protocol presence, standardized assessments to guide protocols, timing of creation of protocols, and estimated adherence to protocols. We also collected data on factors that might be determinants for protocol adoption including ICU staffing models, hospital and ICU level factors. We validated the survey tool using the Michigan Health and Hospital Association Keystone ICU collaborative. We then administered the validated survey to a leader of the medical ICU or mixed medical-surgical ICU of all Pennsylvania Hospitals. Multivariable logistic and ordinal regression were used to determine associations between ICU staffing models and hospital and ICU level factors with the presence of ABCDE bundle protocols. RESULTS In the study cohort of Pennsylvania ICUs (n = 144), we had 100 respondents (69% response). The median number of hospital beds among the respondents was 185 (IQR 111-355) with a median of 14 ICU beds (IQR 10-20). 86% reported spontaneous awakening trial protocols, 60% reported spontaneous breathing trial protocols, 43% reported delirium assessment/management protocols, and 27% reported early mobility protocols. Being a medical ICU compared to a mixed medical-surgical ICU (OR 3.48, 95% CI 1.19-10.21, P = .02) and presence of multidisciplinary rounds (OR 4.97, 95% CI 2.07-11.94, P < .001) were associated with increasing number of ABCDE bundle protocol components. CONCLUSIONS Variable implementation of ABCDE bundle protocols was present across Pennsylvania. Team communication is important to implementation of these protocols.
Collapse
Affiliation(s)
- Rita N Bakhru
- Section of Pulmonary, Critical Care, Allergy and Immunology, Department of Internal Medicine, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Kathleen J Propert
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Steven M Kawut
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William D Schweickert
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
13
|
Schwab Jensen K, Sherman AE, Wang T, Melamed K. A Prospective Trial of an In-house Overnight Fellow Rotation in the Intensive Care Unit. ATS Sch 2022; 3:301-311. [PMID: 37881337 PMCID: PMC10594893 DOI: 10.34197/ats-scholar.2022-0012oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/27/2022] [Indexed: 10/27/2023] Open
Abstract
Background Although previous studies in academic intensive care units (ICUs) have found no improvement in patient care outcomes with in-house overnight attending physician coverage compared with home call coverage, the effect of in-house supervision on trainee education and well-being is less clear. In addition, no studies have examined the effect of in-house coverage by fellow physicians overnight. Objective What is the impact of an in-house overnight critical care fellow on resident, fellow, and attending perception of patient safety, house staff education, and house staff well-being? Methods A prospective trial alternating 2-week periods of in-house overnight critical care fellow coverage with 2-week periods of home call coverage was performed in our tertiary medical ICU. Residents, fellows, and attendings were surveyed to evaluate perceptions of the night fellows' impact on patient care, communication, supervision, educational experience, autonomy, well-being, and job satisfaction. Results Over the 6-month study period, surveys were sent to 83 residents, 22 fellows, and 23 attendings, with completion by 56 (67%), 22 (100%), and 16 (70%), respectively. Overall, 89% of residents, 68% of fellows, and 81% of attendings reported perceived improvements in patient care with an in-house fellow. The in-house fellow was also associated with improved well-being in 79% of residents and 73% of fellows, and 82% of residents felt that it positively impacted education. Conclusion As compared with the traditional home call system, an in-house night critical care fellow can improve the perception of patient care, trainee well-being, and education in a tertiary ICU at an academic hospital.
Collapse
Affiliation(s)
| | | | - Tisha Wang
- Division of Pulmonary and Critical Care Medicine, David Geffen School of
Medicine at the University of California, Los Angeles, Los Angeles,
California
| | - Kathryn Melamed
- Division of Pulmonary and Critical Care Medicine, David Geffen School of
Medicine at the University of California, Los Angeles, Los Angeles,
California
| |
Collapse
|
14
|
Kim MK, Jung EJ, Park S, Kim IK. Timing of Admission to the Surgical Intensive Care Unit is Associated with in-Hospital Mortality. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: The relationship between the timing of admission (work-hours or after-hours) to the intensive care unit (ICU) and mortality among surgical ICU (SICU) patients is unclear. This study aimed to investigate whether admission to SICU during after-hours was associated with in-hospital mortality.Methods: This retrospective cohort study was conducted in a tertiary academic hospital. The data of 571 patients who were admitted to the SICU and whose complete medical records were available were analyzed. Work-hours were defined as 07:00 to 19:00 Monday to Friday, during which the ICU was staffed with intensivists. After-hours were defined as any other time during which the SICU was not staffed with intensivists. The primary outcome measure was in-hospital mortality according to the time of admission (work-hours or after-hours) to the SICU.Results: A total of 333 patients, were admitted to the SICU during work-hours, and 238 patients after-hours. Unplanned admissions (47.1% vs. 33.3%, p < 0.001), acute physiology and chronic health evaluation II score ≥ 25 (23.9% vs. 11.1%, p < 0.001), the need for ventilator support (34.0% vs. 17.4%, p < 0.001), and the use of vasopressors (50.0% vs. 33.3%, p < 0.001) were significantly higher in the after-hours group compared with the work-hours group. Multivariate analyses revealed that the timing of SICU admission was an independent predictor of in-hospital mortality (odds ratio, 2.526; 95% confidence interval, 1.010–6.320; p = 0.048).Conclusion: This study showed that admission to the SICU during after-hours was associated with increased in-hospital mortality.
Collapse
|
15
|
Mookerjee A, Li B, Arora B, Surapaneni R, Rajput V, Van de Ridder M. Micromanagement During Clinical Supervision: Solutions to the Challenges. Cureus 2022; 14:e23523. [PMID: 35495010 PMCID: PMC9038605 DOI: 10.7759/cureus.23523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/26/2022] [Indexed: 11/05/2022] Open
Abstract
Learner autonomy is an invaluable asset in graduate medical education, preparing the trainee to independently face challenges in the future professional settings. Educational institutions face the difficult task of providing a balance between learner autonomy and supervision. In graduate medical education, trainees often prefer less supervision than what is imparted by their attending physician. This increased supervision comes at the cost of learner autonomy and has not exhibited improvement in patient outcomes or safety. When attendings exhibit control over details, the trainees may label them as “micromanagers”. Cardinal features of a micromanager include excessively requesting updates, insisting that the task be done their way, and scrutinizing every detail. This micromanaging behavior is non-conducive to the learning environment and may even contribute to supervisor burnout. The business literature reveals a debate about this very topic. Unfortunately, there is still a lack of literature on micromanagement in graduate medical education. Although a conglomerate of internal factors may lead to excessive supervision in an academic medical institution, we surmise that micromanagement exists because of a complex dynamic between three drivers: accountability, trust, and autonomy. When trainees are held accountable, they learn to take ownership for their actions which leads to establishment of trust which further enables motivation and gaining of autonomy. Supervising attendings should ideally be able to comfortably adjust their level of supervision based on their trust and the trainee’s competence, accountability, and autonomy. The micromanaging physician is unable to do so, and this can have a detrimental effect on the learner. Micromanagement can be perceived by some as a beneficial component during the early immersion of the trainee with the rationalization for better patient outcomes and safety. However, in the long term, it threatens the learning environment and erodes the complex relationship between accountability, trust, and autonomy. We recommend an action plan to mitigate micromanagement at three levels-the micromanager, the micromanaged, and the organizational structure-and hope that these solutions enhance the learning environment for both the trainee and supervisor.
Collapse
|
16
|
French HM, Leeman KT, Wambach JA, Malik SK, Reber KM. Essentials of Neonatal-Perinatal Medicine fellowship: an overview. J Perinatol 2022; 42:269-276. [PMID: 33649441 DOI: 10.1038/s41372-021-00973-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/04/2021] [Accepted: 01/27/2021] [Indexed: 11/09/2022]
Abstract
Neonatal-Perinatal Medicine (NPM) fellowship programs have undergone constant evolution since their first appearance in the 1960s. This article is the first in a seven-part series (Table 1) that critically evaluates the essentials of neonatology fellowship clinical and research education, performance assessment, and administrative support necessary to support NPM fellowship programs. This overview article will provide background on the history of NPM fellowship programs and provide a framework for the article series. Table 1 Essentials of NPM fellowship article series. Essentials of NPM fellowship Part 1: Overview of NPM fellowship Description of the evolution of NPM Fellowship Part 2: Clinical education and experience Strengths, weaknesses, opportunities, and threats of clinical education in NPM fellowship Part 3: Scholarship opportunities and threats Scholarship requirements during NPM fellowship Part 4: Innovations in medical education Critical analysis of current educational practices and andragogical innovations in NPM fellowship Part 5: Evaluation of competence and proficiency using milestones Assessment of NPM fellows during training using competency-based medical education principles Part 6: Program administration Administrative infrastructure and stakeholders necessary to run a NPM fellowship program Part 7: Careers in NPM Career preparation and opportunities for NPM fellowship graduates.
Collapse
Affiliation(s)
- Heather M French
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Kristen T Leeman
- Department of Pediatrics, Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jennifer A Wambach
- Washington University School of Medicine, St. Louis, MO, USA.,St. Louis Children's Hospital, St. Louis, MO, USA
| | - Sabrina K Malik
- Department of Pediatrics, Division of Neonatology, Joseph M. Sanzari Children's Hospital, Hackensack, NJ, USA.,Hackensack Meridian Health School of Medicine, Hackensack, NJ, USA
| | | | - Kristina M Reber
- Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
| |
Collapse
|
17
|
Parental Perspectives on Neonatologist Continuity of Care. Adv Neonatal Care 2021; 21:E162-E170. [PMID: 34138794 DOI: 10.1097/anc.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuity of care (COC) is highly regarded; however, data about benefits are mixed. Little is known about components, parental views, or the value COC may provide to neonatal intensive care unit (NICU) infants and families. PURPOSE To describe parents' perspectives on definitions, reasons they value, and suggested improvements regarding COC provided by neonatologists. METHODS We performed a qualitative study of in-person, semistructured interviews with parents of NICU infants hospitalized for 28 days or more. We analyzed interview transcripts using content analysis, identifying codes of parental experiences, expressed value, and improvement ideas related to neonatologist COC, and categorizing emerging themes. RESULTS Fifteen families (15 mothers and 2 fathers) described 4 themes about COC: (1) longitudinal neonatologists: gaining experience with infants and building relationships with parents over time; (2) background knowledge: knowing infants' clinical history and current condition; (3) care plans: establishing patient-centered goals and management plans; and (4) communication: demonstrating consistent communication and messaging. Parents described benefits of COC as decreasing knowledge gaps, advancing clinical progress, and decreasing parental stress. Suggested improvement strategies included optimizing staffing and sign-out/transition processes, utilizing clinical guidelines, and enhancing communication. Using parent input and existing literature, we developed a definition and conceptual framework of COC. IMPLICATIONS FOR PRACTICE NICUs should promote practices that enhance COC. Parental suggestions can help direct improvement efforts. IMPLICATIONS FOR RESEARCH Our COC definition and conceptual framework can guide development of research and quality improvement projects. Future studies should investigate nursing perspectives on NICU COC and the impact of COC on infant and family outcomes.
Collapse
|
18
|
Outcomes of daytime nurse practitioner-staffed versus resident-staffed nonsurgical intensive care units: A retrospective observational study. Aust Crit Care 2021; 35:630-635. [PMID: 34857440 DOI: 10.1016/j.aucc.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/10/2021] [Accepted: 10/10/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Rapid developments in medical care-such as monitoring devices, medications, and working hours restrictions for intensive care personnel-have dramatically increased the demand for intensive care physicians. Therefore, nurse practitioner (NP)-staffed care is becoming increasingly important. This study was aimed to compare the outcomes of daytime NP-staffed and daytime resident-staffed nonsurgical intensive care units (ICU). METHODS We retrospectively assessed patients admitted to a nonsurgical ICU from March 2017 to December 2017. We collected basic patient data, including age, sex, admission diagnosis, transferring unit, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Primary endpoints were ICU mortality, hospital mortality, and 30-day mortality. Secondary endpoints were 48-h readmission, discharge to nonhome locations, and lengths of ICU and hospital stay. RESULTS A total of 838 subjects were analysed: 334 subjects in the NP-staffed group and 504 in the resident-staffed group. The NP-staffed group was more likely to come from inpatient units (38.3% vs 16.5% for resident-staffed group; p < 0.001) and had lower disease severity (APACHE II score, 13.9 ± 8.4 vs 15.1 ± 8.2 for resident-staffed group; p = 0.047). After adjusting for age, sex, location before ICU admission, APACHE II score, and significantly different basic characteristics, there were no differences in ICU mortality, hospital mortality, or 30-day mortality between the two groups. Secondary analysis showed the NP-staffed group had a lower discharge rate to nonhome locations (2.1% vs 6.3%; p = 0.023) and shorter hospital stay (12.1 ± 14.1 vs 14.2 ± 14.3 days; p = 0.015). CONCLUSIONS We observed no difference in mortality between daytime NP-staffed and resident-staffed nonsurgical ICUs. Daytime NP-staffed care is an effective, safe, feasible method for staffing nonsurgical ICUs.
Collapse
|
19
|
Okazaki T, Yoshida T, Uchino S, Sasabuchi Y. Association of onset time of new-onset atrial fibrillation with in-hospital mortality among critically ill patients: A secondary analysis of a prospective multicenter observational study. IJC HEART & VASCULATURE 2021; 36:100880. [PMID: 34632043 PMCID: PMC8488237 DOI: 10.1016/j.ijcha.2021.100880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/01/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022]
Abstract
Background New-onset atrial fibrillation (AF) in critically ill patients is associated with adverse outcomes. In non-critical settings, the circadian variation in paroxysmal AF is of significant interest; however, circadian variation in critically ill patients with new-onset AF has not been thoroughly studied. This study aimed to examine the association between AF onset time and in-hospital mortality. Methods This was a secondary analysis of a prospective multicenter observational study enrolling adult critically ill patients. According to AF onset time, patients were divided into nighttime (0:00–7:59), daytime (8:00–15:59), and evening (16:00–23:59). We conducted a multiple logistic regression analysis to assess the potential association between AF onset time and in-hospital mortality. We also assessed the distribution of AF onset, crude in-hospital mortality, and adjusted in-hospital mortality according to bihourly intervals. Results Of 423 patients, in-hospital mortality was 26%. During nighttime, 135 patients (32%) developed new-onset AF. AF emerged during daytime for 141 (33%) and during evening for 147 (35%). Daytime AF was significantly associated with an increased risk of in-hospital mortality (adjusted OR: 1.92; 95% CI: 1.07–3.44; p = 0.030). Bihourly interval analysis showed that adjusted in-hospital mortality was unevenly distributed and bimodal with troughs between 6:00 and 7:59 and between 18:00 and 19:59. A similar trend was seen in the distribution of the number of new-onset AF. Conclusions We found that the bihourly adjusted in-hospital mortality was distributed in a bimodal fashion. Further research is needed to determine the causes of the diurnal variation and its impact on patient outcomes.
Collapse
Affiliation(s)
- Tomoya Okazaki
- Emergency Medical Center, Kagawa University Hospital, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Japan.,Department of Intensive Care Medicine, Tokyo Women's Medical University, Japan
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Japan
| | | | | |
Collapse
|
20
|
Nizamuddin J, Tung A. Con: 24/7 In-House Intensivist Coverage is Not Required for CTICU Management. J Cardiothorac Vasc Anesth 2021; 35:3437-3439. [PMID: 34376344 DOI: 10.1053/j.jvca.2021.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/11/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Junaid Nizamuddin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| |
Collapse
|
21
|
Kidd B, Flynn BC. Pro: 24/7 In-House Intensivist Coverage in the CTICU. J Cardiothorac Vasc Anesth 2021; 35:3434-3436. [PMID: 34373180 DOI: 10.1053/j.jvca.2021.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/11/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Brent Kidd
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS.
| |
Collapse
|
22
|
Watson SI, Lilford RJ, Sun J, Bion J. Estimating the effect of health service delivery interventions on patient length of stay: A Bayesian survival analysis approach. J R Stat Soc Ser C Appl Stat 2021. [DOI: 10.1111/rssc.12501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | | | - Jianxia Sun
- University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | | |
Collapse
|
23
|
In-House, Overnight Physician Staffing: A Cross-Sectional Survey of Canadian Adult ICUs. Crit Care Med 2021; 48:e1203-e1210. [PMID: 33031147 DOI: 10.1097/ccm.0000000000004598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Overnight physician staffing in the ICU has been recommended by the Society of Critical Care Medicine and the Leapfrog Consortium. We conducted a survey to review practice in the current era and to compare this with results from a 2006 survey. DESIGN Cross-sectional survey. SETTING Canadian adult ICUs. PARTICIPANTS ICU directors. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS A 29-question survey was sent to ICU directors describing overnight staffing by residents, fellows, nurse practitioners, and staff physicians, as well as duty duration, clinical responsibilities, and unit characteristics. We established contact with 122 ICU directors, of whom 107 (88%) responded. Of the 107 units, 60 (56%) had overnight in-house physicians. Compared with ICUs without overnight in-house physician coverage, ICUs with in-house physicians were in larger hospitals (p < 0.0001), had more beds (p < 0.0001), had more ventilated patients (p < 0.0001), and had more admissions (p < 0.0001). Overnight in-house physicians were first year residents (R1) in 20 of 60 (33%), second to fifth year residents (R2-R5) in 46 of 60 (77%), and Critical Care Medicine trainees in 19 of 60 (32%). Advanced practice nurses provided overnight coverage in four of 107 ICUs (4%). The most senior in-house physician was a staff physician in 12 of 60 ICUs (20%), a Critical Care Medicine trainee in 14 of 60 (23%), and a resident (R2-R5) in 20 of 60 (33%). The duration of overnight duty was on average 20-24 hours in 22 of 46 units (48%) with R2-R5 residents and 14 of 19 units (74%) covered by Critical Care Medicine trainees. CONCLUSIONS Variability of in-house overnight physician presence in Canadian adult ICUs is linked to therapeutic complexity and unit characteristics and has not changed significantly over the decade since our 2006 survey. Additional evidence about patient and resident outcomes would better inform decisions to revise physician scheduling in Canadian ICUs.
Collapse
|
24
|
Fusaro MV, Becker C, Miller D, Hassan IF, Scurlock C. ICU Telemedicine Implementation and Risk-Adjusted Mortality Differences Between Daytime and Nighttime Coverage. Chest 2020; 159:1445-1451. [PMID: 33127432 DOI: 10.1016/j.chest.2020.10.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND ICU telemedicine augmentation has been associated with improvements in clinical and financial outcomes in many cases, but not all. Understanding this discrepancy is of interest given the clinical impact and intervention cost. A recent meta-analysis noted an association with mortality reduction and standardized mortality ratio (SMR) before ICU telemedicine implementation of > 1. RESEARCH QUESTION Does ICU telemedicine implementation affect adjusted mortality outcomes? If so, in what context? STUDY DESIGN AND METHODS We performed a retrospective pre-post analysis comparing before vs after ICU telemedicine implementation on the outcome of risk-adjusted ICU mortality during am vs pm admissions as well as other objective measures of ICU telemedicine involvement. RESULTS One thousand five hundred eighty-one patient-stays and 14,584 patient-stays were available for analysis in the implementation period before vs after ICU telemedicine implementation, respectively. The average Acute Physiology and Chronic Health Evaluation (APACHE) IVa score was 46.6 vs 54.8 (P < .01) in the am group before ICU telemedicine implementation vs the am group after ICU telemedicine implementation, respectively. The average APACHE IVa score was 47.2 vs 56.3 (P < .01) in the pm group before ICU telemedicine implementation vs the pm group after ICU telemedicine implementation, respectively. Overall, the risk-adjusted ICU mortality was 8.7% before ICU telemedicine implementation vs 6.5% (P < .01) after implementation. When stratified by am and pm admission groups, no significant difference in risk-adjusted ICU mortality was seen in the am stratum. In the pm stratum, risk-adjusted mortality was 10.8% before ICU telemedicine implementation vs 7.0% (P < .01) after ICU telemedicine implementation. The preimplementation SMR in the am admission stratum was 0.95 vs 1.30 in the pm stratum. INTERPRETATION We found a reduction in risk-adjusted ICU mortality with implementation of ICU telemedicine driven predominantly within the pm admission group. The pm admission SMR was 1.30, which may suggest an association with SMR of > 1 before ICU telemedicine implementation and mortality reduction. Future studies should seek to confirm this finding and should explore other important ICU telemedicine outcomes in the context of observed-to-expected ratios.
Collapse
Affiliation(s)
- Mario V Fusaro
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network, Valhalla, NY.
| | - Christian Becker
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network, Valhalla, NY
| | - Daniel Miller
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network, Valhalla, NY
| | - Ibrahim F Hassan
- Departments of Medicine and Genetic Medicine, Weill Cornell Medical College, Al Luqta St, Education City, Qatar
| | - Corey Scurlock
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network, Valhalla, NY; Department of Anesthesiology, Westchester Medical Center Health Network, Valhalla, NY
| |
Collapse
|
25
|
Aziz A, Hawkins A, Gainer Y, Simpson C, Barlow R, Varma C. General medicine consultant of the week model shortens hospital length of stay and improves the patient journey. Future Healthc J 2020; 7:218-221. [PMID: 33094232 DOI: 10.7861/fhj.2019-0057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS The consultant of the week (COW) model of inpatient care means the consultants' primary focus is to deliver ward-based care daily. At Sandwell and West Birmingham Hospitals NHS Trust, a COW model has been successfully used for cardiology and stroke services. This has improved continuity of care and developed a 7-day working week. Our aim was to extend this model to all general medical consultants who manage inpatients. METHODS We introduced the COW model to the unselected general medical take. Restructuring of consultant job plans allowed daily ward presence, 5 days per week. Outcome measures included length of stay (LOS) and accuracy of expected date of discharge (EDD). RESULTS LOS over a 12-month period improved from an average of 9.17 days to 6.61 days. The number of EDD changes reduced, from a previous average of 3.0 changes to 1.8 changes. Consultant feedback showed there was an improvement in collaboration between teams, improved training of junior doctors and higher job satisfaction. CONCLUSIONS Improved 5-day consultant presence is associated with reduced LOS. Learning points included the delay in implementation due to the complexity of consultant job planning. We plan to extend COW to 7-days for all general medical wards.
Collapse
Affiliation(s)
- Amir Aziz
- Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - April Hawkins
- Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | | | - Craig Simpson
- Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Rachel Barlow
- Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Chetan Varma
- Sandwell and West Birmingham NHS Trust, Birmingham, UK
| |
Collapse
|
26
|
Sabin JE, Cocoros NM, Garcia CJ, Goldsack JC, Haynes K, Lin ND, McCall D, Nair V, Pokorney SD, McMahill-Walraven CN, Granger CB, Platt R. Bystander Ethics and Good Samaritanism: A Paradox for Learning Health Organizations. Hastings Cent Rep 2020; 49:18-26. [PMID: 31429964 DOI: 10.1002/hast.1031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In 2012, a U.S. Institute of Medicine report called for a different approach to health care: "Left unchanged, health care will continue to underperform; cause unnecessary harm; and strain national, state, and family budgets." The answer, they suggested, would be a "continuously learning" health system. Ethicists and researchers urged the creation of "learning health organizations" that would integrate knowledge from patient-care data to continuously improve the quality of care. Our experience with an ongoing research study on atrial fibrillation-a trial known as IMPACT-AFib-gave us some insight into one of the challenges that will have to be dealt with in creating these organizations. Although the proposed educational intervention study placed no restrictions on what providers and health plans could do, the oversight team argued that the ethical principle of beneficence did not allow the researchers to be "bystanders" in relation to a control group receiving suboptimal care. In response, the researchers designed a "workaround" that allowed the project to go forward. We believe the experience suggests that what we call "bystander ethics" will create challenges for the kinds of quality improvement research that LHOs are designed to do.
Collapse
|
27
|
Huard P, Kalavrouziotis D, Lipes J, Simon M, Tardif MA, Blackburn S, Langevin S, Sia YT, Mohammadi S. Does the full-time presence of an intensivist lead to better outcomes in the cardiac surgical intensive care unit? J Thorac Cardiovasc Surg 2020; 159:1363-1375.e7. [DOI: 10.1016/j.jtcvs.2019.03.124] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 10/26/2022]
|
28
|
Influence of a high-intensity staffing model in a cardiac surgery intensive care unit on postoperative clinical outcomes. J Thorac Cardiovasc Surg 2020; 159:1382-1389. [DOI: 10.1016/j.jtcvs.2019.04.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022]
|
29
|
Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing. Crit Care Med 2020; 47:894-902. [PMID: 30985450 DOI: 10.1097/ccm.0000000000003773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model. DESIGN Prospective observational study. SETTING Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing. PATIENTS Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012. INTERVENTIONS As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily. MEASUREMENTS AND MAIN RESULTS Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model. CONCLUSIONS Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.
Collapse
|
30
|
Is 24/7 In-Hospital Coverage Mutually Beneficial for Patients and Intensivists? Crit Care Med 2020; 47:999. [PMID: 31205081 DOI: 10.1097/ccm.0000000000003792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
31
|
Thorpe CM. Intensive care medicine in smaller hospitals: here to stay. Future Healthc J 2020; 7:28-32. [PMID: 32104762 DOI: 10.7861/fhj.2019-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Intensive care medicine is a relatively new specialty. In developing standards of care, it became apparent that some aspects were not achievable by smaller units. Within the intensive care community, there has been a gradual acceptance that smaller hospitals cannot necessarily implement structures that are used in large hospitals, and that outcomes can be comparable with larger units despite this. The Faculty of Intensive Care Medicine set up a Smaller and Specialist Units Advisory Group to explore this area, and this article initially explains the background and work of the faculty to support and sustain these units. We then move on to look at critical care in the context of the recent emergence of wider work on remote and rural healthcare. Finally, we explore our future horizons and look in detail at the areas where further developments will transform the care of critically ill patients within the smaller hospitals of the next 20 years.
Collapse
Affiliation(s)
- Christopher M Thorpe
- Ysbyty Gwynedd, Bangor, UK and chair of the Smaller and Specialist Units Advisory Group, The Faculty of Intensive Care Medicine, London, UK
| |
Collapse
|
32
|
Affiliation(s)
- David J Wallace
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|
33
|
Ryskina KL, Dynan L, Stein R, Fieldston E, Palakshappa D. Diagnostic Testing During Pediatric Hospitalizations: The Role of Attending In-House Coverage and Daytime Exposure. Acad Pediatr 2020; 20:508-515. [PMID: 31648058 PMCID: PMC7170750 DOI: 10.1016/j.acap.2019.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/19/2019] [Accepted: 09/25/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Overuse of diagnostic tests is of particular concern for pediatric academic medical centers. Our objective was to measure variation in testing based on proportion of hospitalization during the day versus night and the association between attending in-house coverage on the teaching service and test utilization for hospitalized pediatric patients. METHODS Electronic health record data from 11,567 hospitalizations to a large, Northeastern, academic pediatric hospital were collected between January 2007 and December 2010. The patient-level dataset included orders for laboratory and imaging tests, information about who placed the order, and the timing of the order. Using a cross-sectional effect modification analysis, we estimated the difference in test utilization attributable to attending in-house coverage. RESULTS We found that admission to the teaching service was independently associated with higher utilization of laboratory and imaging tests. However, the number of orders was 0.76 lower (95% confidence interval:-1.31 to -0.21, P = .006) per 10% increase in the proportion in the share of the hospitalization that occurred during daytime hours on the teaching services, which is attributable to direct attending supervision. CONCLUSIONS Direct attending care of hospitalized pediatric patients at night was associated with slightly lower diagnostic test utilization.
Collapse
Affiliation(s)
- Kira L. Ryskina
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Linda Dynan
- Department of Economics and Finance, Northern Kentucky University, Highland Heights, KY; and Anderson Center for Health System Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Rebecca Stein
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Evan Fieldston
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, PA
| | - Deepak Palakshappa
- Division of General Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
34
|
Williams V, Jaiswal N, Chauhan A, Pradhan P, Jayashree M, Singh M. Time of Pediatric Intensive Care Unit Admission and Mortality: A Systematic Review and Meta-Analysis. J Pediatr Intensive Care 2019; 9:1-11. [PMID: 31984150 DOI: 10.1055/s-0039-3399581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/03/2019] [Indexed: 01/21/2023] Open
Abstract
The aim of this study was to determine the association between the time of admission (day, night, and/or weekends) and mortality among critically ill children admitted to a pediatric intensive care unit (PICU). Electronic databases that were searched include PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Ovid, and Cochrane Library since inception till June 15, 2018. The article included observational studies reporting inhospital mortality and the time of admission to PICU limited to patients aged younger than 18 years. Meta-analysis was performed by a frequentist approach with both fixed and random effect models. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was used to evaluate the quality of evidence. Ten studies met our inclusion criteria. Five studies comparing weekday with weekend admissions showed better odds of survival on weekdays (odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.60-0.99). Pooled data of four studies showed that odds of mortality were similar between day and night admissions (OR: 0.93; 95% CI: 0.77-1.13). Similarly, three studies comparing admission during off-hours versus regular hours did not show better odds of survival during regular hours (OR: 0.77; 95% CI: 0.57-1.05). Heterogeneity was significant due to variable sample sizes and time period. Inconsistency in adjusting for confounders across the included studies precluded us from analyzing the adjusted risk of mortality. Weekday admissions to PICU were associated with lesser odds of mortality. No significant differences in the odds of mortality were found between admissions during day versus night or between admission during regular hours and that during off-hours. However, the evidence is of low quality and requires larger prospective studies.
Collapse
Affiliation(s)
- Vijai Williams
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Nishant Jaiswal
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India.,Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Anil Chauhan
- Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Pranita Pradhan
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Muralidharan Jayashree
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Meenu Singh
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India.,Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| |
Collapse
|
35
|
Harhay MO, Ratcliffe SJ, Small DS, Suttner LH, Crowther MJ, Halpern SD. Measuring and Analyzing Length of Stay in Critical Care Trials. Med Care 2019; 57:e53-e59. [PMID: 30664613 PMCID: PMC6635104 DOI: 10.1097/mlr.0000000000001059] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In randomized clinical trials among critically ill patients, it is uncertain how choices regarding the measurement and analysis of nonmortal outcomes measured in terms of duration, such as intensive care unit (ICU) length of stay (LOS), affect studies' conclusions. OBJECTIVES Assess the definitions and analytic methods used for ICU LOS analyses in published randomized clinical trials. RESEARCH DESIGN This is a systematic review and statistical simulation study. RESULTS Among the 80 of 150 trials providing sufficient information regarding the chosen definition of ICU LOS, 3 different start times (ICU admission, trial enrollment/randomization, receipt of intervention) and 2 end times (discharge readiness, actual discharge) were used. In roughly three quarters of these studies, ICU LOS was compared using approaches that did not explicitly account for death, either by ignoring it entirely or stratifying the analyses by survival status. The remaining studies used time-to-event (discharge) models censoring at death or applied a fixed LOS value to patients who died. In statistical simulations, we showed that each analytic approach tested a different question regarding ICU LOS, and that approaches that do not explicitly account for death often produce misleading or ambiguous conclusions when treatments produce small effects on mortality, even if those are not detected as significant in the trial. CONCLUSIONS There is considerable variability in how ICU LOS is measured and analyzed which impairs the ability to compare results across trials and can produce spurious conclusions. Analyses of duration-based outcomes such as LOS should jointly assess the impact of the intervention on mortality to yield correct interpretations.
Collapse
Affiliation(s)
- Michael O Harhay
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
| | - Sarah J Ratcliffe
- Department of Public Health Sciences, University of Virginia, Division of Biostatistics, Charlottesville, VA
| | - Dylan S Small
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
- Department of Statistics, Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Leah H Suttner
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Michael J Crowther
- Biostatistics Research Group, Department of Health Sciences, Centre for Medicine, University of Leicester, Leicester, UK
| | - Scott D Halpern
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
36
|
Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance. Pediatr Crit Care Med 2019; 20:847-887. [PMID: 31483379 DOI: 10.1097/pcc.0000000000001963] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. DESIGN A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. METHODS The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. RESULTS The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. CONCLUSIONS This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.
Collapse
|
37
|
Arora RC, Chatterjee S, Shake JG, Hirose H, Engelman DT, Rabin J, Firstenberg M, Moosdorf RGH, Geller CM, Hiebert B, Whitman GJ. Survey of Contemporary Cardiac Surgery Intensive Care Unit Models in the United States. Ann Thorac Surg 2019; 109:702-710. [PMID: 31421102 DOI: 10.1016/j.athoracsur.2019.06.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/02/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Intensive care unit (ICU) structure and intensive care physician staffing (IPS) models are thought to influence outcomes after cardiac surgery. Given limited information on staffing in the cardiothoracic ICU, The Society of Thoracic Surgeons Workforce on Critical Care undertook a survey to describe current IPS models. We hypothesized that variability would exist throughout the United States. METHODS A survey was sent to The Society of Thoracic Surgeons centers in the United States. Center case volume, ICU census, procedure profiles, and the primary specialties of consultants were queried. Definitions of IPS models were open (managed by cardiac surgeons), closed (all decisions made by dedicated intensivists 7 days a week), or semiopen (intensivist attends 5-7 days a week with surgeons cosharing management). Experience level of bedside providers and after-hours provider coverage were also assessed. RESULTS Of the 965 centers contacted, 148 (15.3%) completed surveys. Approximately 41% of reporting centers used a dedicated cardiothoracic ICU for immediate postoperative management. The most common IPS model was open (47%), followed by semiopen (41%) and closed (12%). The primary specialties of intensivists varied, with pulmonary medicine/critical care being predominant (67%). Physician assistants were the most common after-hours provider (44%). More than one-third of responding centers described having no house staff, other than bedside nurses, for nighttime coverage. CONCLUSIONS Cardiothoracic ICU models vary widely in the United States, with almost half being open, often with no in-house coverage. In-house nighttime coverage was (1) not driven by case complexity and (2) most commonly provided by a physician assistant. Clinical outcomes associated with different ISPS models require further evaluation.
Collapse
Affiliation(s)
- Rakesh C Arora
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
| | | | - Jay G Shake
- Department of Surgery, University of Mississippi, Jackson, Mississippi
| | - Hitoshi Hirose
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Dan T Engelman
- Department of Surgery, Baystate Medical Center, Springfield, Massachusetts
| | - Joseph Rabin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Firstenberg
- Department of Cardiovascular Surgery, The Medical Center of Aurora, Aurora, Colorado
| | - Rainer G H Moosdorf
- Department for Cardiovascular Surgery, Phillips University, Marburg, Germany
| | - Charles M Geller
- Division of Cardiothoracic Surgery, Drexel University College of Medicine, Upland, Pennsylvania
| | - Brett Hiebert
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Glenn J Whitman
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins Medical Institute, Baltimore, Maryland
| | | |
Collapse
|
38
|
Abstract
PURPOSE OF REVIEW Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental. RECENT FINDINGS Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens. SUMMARY Most potential HAP prevention strategies remain unproven.
Collapse
|
39
|
Ramakrishnan M, Taduru SS, Patel P, Younis M, Hamarshi M. External Intensivists Versus In-House Intensivists: Analysis of Outcomes of Nighttime Coverage of ICUs by External On-Call and In-House On-Call Intensivists. MISSOURI MEDICINE 2019; 116:331-335. [PMID: 31527984 PMCID: PMC6699813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A 24/7 intensivist model may improve important outcomes such as mortality, length of stay, and number of ventilator days. In this retrospective, single-center study at Saint Luke's Hospital in Kansas City, Missouri, we examined patient outcomes before and after adopting a 24/7 model from 2014 to 2016. The addition of a nighttime intensivist did not lead to a statistically significant improvement in mortality (hospital and ICU) and LOS (hospital and ICU).
Collapse
Affiliation(s)
- Madhuri Ramakrishnan
- Madhuri Ramakrishnan, MD, Siva Sagar Taduru, MD, Parth Patel, MD, and Mustafa Younis, MD, are residents in the Department of Internal Medicine, University of Missouri - Kansas City. Majdi Hamarshi, MD, is Staff, Critical Care Medicine and Geriatric Medicine, Saint Luke's Health System, Kansas City, Mo
| | - Siva Sagar Taduru
- Madhuri Ramakrishnan, MD, Siva Sagar Taduru, MD, Parth Patel, MD, and Mustafa Younis, MD, are residents in the Department of Internal Medicine, University of Missouri - Kansas City. Majdi Hamarshi, MD, is Staff, Critical Care Medicine and Geriatric Medicine, Saint Luke's Health System, Kansas City, Mo
| | - Parth Patel
- Madhuri Ramakrishnan, MD, Siva Sagar Taduru, MD, Parth Patel, MD, and Mustafa Younis, MD, are residents in the Department of Internal Medicine, University of Missouri - Kansas City. Majdi Hamarshi, MD, is Staff, Critical Care Medicine and Geriatric Medicine, Saint Luke's Health System, Kansas City, Mo
| | - Mustafa Younis
- Madhuri Ramakrishnan, MD, Siva Sagar Taduru, MD, Parth Patel, MD, and Mustafa Younis, MD, are residents in the Department of Internal Medicine, University of Missouri - Kansas City. Majdi Hamarshi, MD, is Staff, Critical Care Medicine and Geriatric Medicine, Saint Luke's Health System, Kansas City, Mo
| | - Majdi Hamarshi
- Madhuri Ramakrishnan, MD, Siva Sagar Taduru, MD, Parth Patel, MD, and Mustafa Younis, MD, are residents in the Department of Internal Medicine, University of Missouri - Kansas City. Majdi Hamarshi, MD, is Staff, Critical Care Medicine and Geriatric Medicine, Saint Luke's Health System, Kansas City, Mo
| |
Collapse
|
40
|
Time of admission to intensive care unit, strained capacity, and mortality: A retrospective cohort study. J Crit Care 2019; 54:1-6. [PMID: 31306832 DOI: 10.1016/j.jcrc.2019.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE We sought to study the association between afterhours ICU admission and ICU mortality considering measures of strained ICU capacity. MATERIALS AND METHODS Retrospective analysis of 4141 admissions to 2 ICUs in Lisbon, Portugal (06/2016-06/2018). Primary exposure was ICU admission on 20:00 h-07:59 h. Primary outcome was ICU mortality. Measures of strained ICU capacity were: bed occupancy rate ≥ 90% and cluster of ICU admissions 2 h before or following index admission. RESULTS There were 1581 (38.2%) afterhours ICU admissions. Median APACHE II score (19 vs. 20) was similar between patients admitted afterhours and others (P = .27). Patients admitted afterhours had higher crude ICU mortality (15.4% vs. 21.9%; P < .001), but similar adjusted ICU mortality (aOR [95%CI] = 1.15 [0.97-1.38]; P = .12). While bed occupancy rate ≥ 90% was more frequent in patients admitted afterhours (23.1% vs. 29.1%) or deceased in ICU (23.6% vs. 33.7%), cluster of ICU admissions was more frequent in patients admitted during daytime hours (75.2% vs. 58.9%) or that survived the ICU stay (70.1% vs. 63.9%; P ≤ .001 for all). These measures of strained ICU capacity were not associated with adjusted ICU mortality (P ≥ .10 for both). CONCLUSIONS Afterhours ICU admission and measures of strained ICU capacity were associated with crude but not adjusted ICU mortality.
Collapse
|
41
|
Abstract
PURPOSE OF REVIEW Many hospitals, particularly large academic centers, have begun to provide 24-h in-house intensive care attending coverage. Proposed advantages for this model include improved patient care, greater provider, nursing and patient satisfaction, better communication, and greater cost-effectiveness. This review will evaluate current evidence with respect to 24/7 coverage, including patient outcomes, cost-effectiveness, and impact on training/education. RECENT FINDINGS Evidence surrounding 24-h intensivist staffing has been mixed. Although a subset of studies suggest a possible benefit to 24-h intensivist coverage, recent prospective studies have shown no difference in major patient outcomes, including mortality and ICU length of stay between patients in ICUs with and those without 24-h intensivist coverage. SUMMARY Although some studies cite increased caregiver and patient satisfaction, outcome studies find no consistent effect on patient-centered outcomes such as mortality or length of stay. Downsides to in-house nighttime attending staffing include physician burnout, adverse effects on physician health, decreased trainee autonomy, and effects on trainee specialty choices because of undesirable lifestyle considerations. Tele-ICU and other novel approaches may allow for attending supervision without physical presence.
Collapse
|
42
|
Stick to What You Know: Do Visiting Intensivists Worsen Outcomes? Crit Care Med 2019; 45:1095-1096. [PMID: 28509732 DOI: 10.1097/ccm.0000000000002424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
43
|
Metkus TS, Whitman GJR. Commentary: Nighttime stars: Intensivist coverage and cardiac surgical outcomes. J Thorac Cardiovasc Surg 2019; 159:1376-1377. [PMID: 31255343 DOI: 10.1016/j.jtcvs.2019.04.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Thomas S Metkus
- Division of Cardiology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
| |
Collapse
|
44
|
van Diepen S. Commentary: More evidence for 24-7 intensivist cardiac surgical intensive care unit coverage. J Thorac Cardiovasc Surg 2019; 159:1380-1381. [PMID: 31060738 DOI: 10.1016/j.jtcvs.2019.03.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/21/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
45
|
Koch J, Das SR. Rapid Response Teams in Pediatric Patients: Well Intentioned, but Do They Really Help? Circulation 2019; 137:47-48. [PMID: 29279338 DOI: 10.1161/circulationaha.117.031597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joshua Koch
- Division of Critical Care, Department of Pediatrics (J.K.)
| | - Sandeep R Das
- Division of Cardiology, Department of Internal Medicine (S.R.D.), University of Texas Southwestern Medical Center, Dallas
| |
Collapse
|
46
|
Seniorization of Tasks in the Academic Medical Center: A Worrisome Trend. J Am Coll Surg 2019; 228:299-302. [DOI: 10.1016/j.jamcollsurg.2018.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 01/24/2023]
|
47
|
Sendur SN, Topeli A. The effect of the first-year residents orientation period on intensive care and hospital mortality, in a medical intensive care unit, within a developing country. J Crit Care 2019; 51:105-110. [PMID: 30798097 DOI: 10.1016/j.jcrc.2019.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To determine whether the adaptation of junior residents, during their first week rotation period within the ICU, has any effect on ICU and hospital mortality rates, in a developing country. MATERIALS AND METHODS Patients who were admitted to the ICU were included, with 1207 out of 1547 of the admitted patients being eligible. The effect of age, gender, co-morbidities, the cause of the ICU admission, the presence of hospital-acquired infections, residents rotation week, admission time (weekday vs. weekend), number of patients admitted on the same day (one vs. two or more) and APACHE II score upon the ICU and hospital mortality rates were evaluated. RESULTS The first rotation week of junior residents is an independent risk factor determining hospital mortality (OR (95% CI) = 2.42 (1.23-4.76); p = .010). The effect of the first rotation week on intensive care mortality was not statistically significant (1.92 (0.97-3.84); p = .063). In addition, the presence of malignancy, sepsis-septic shock, hospital-acquired infection and high APACHE II score were found to be other independent determinants of increased hospital mortality. CONCLUSION The junior residents first rotation week is an independent risk factor on hospital mortality, in a tertiary medical intensive care unit, within a developing country.
Collapse
Affiliation(s)
- Suleyman Nahit Sendur
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.
| | - Arzu Topeli
- Division of Intensive Care Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| |
Collapse
|
48
|
Min-Jie J, Zhun-Yong G, Yan H, Yu-Jing L, Hong-Yu H, Yi-Mei L, Guo-Wei T, Jian-Feng L, Du-Ming Z, Zhe L. The 24-Hour Intensivists Staffing Model Improves the Outcome for Nighttime Admitted Patients: A Matched Historical Control Study. J Intensive Care Med 2019; 35:1439-1446. [PMID: 30744471 DOI: 10.1177/0885066619828338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION We previously showed that a "10-hour daytime on-site" and "nighttime (NT) on-call" staffing strategy was associated with higher mortality for intensive care unit (ICU) patients admitted during NT than it was for patients admitted during office hours (OH). In here, we evaluated the clinical effects of a 24-hour intensivist staffing model. METHODS We formed an intervention group of 3034 consecutive ICU patients hospitalized from January 2013 to December 2015, and a control group of 2891 patients from our previous study (2009-2011). We applied propensity score matching (PSM) for whole and subgroup analyses adjusting for confounding factors. We compared clinical outcomes of patients under the 2 staffing models using multivariate logistic regression and survival analyses. RESULTS After PSM, we balanced the clinical data between the complete cohorts and the subgroups. Comparison of ICU survivals between the intervention and control cohorts yielded no significant differences. However, the intervention was significantly associated with a higher ICU survival in the NT (5:30 pm-07:30 am) admission patients (P = .049) than in those admitted during OH (07:30 am to 5:30 pm; P = .456). Additionally, the intervention shortened the LOSHOS (P = .001) and/or LOSICU (P < .001), reduced the hospital (P = .672) and/or ICU (P = .004) expenses, and resulted in earlier mechanical ventilation extubation (P = .442) as compared to the same variables in the control group, especially for NT admissions. CONCLUSIONS The 24-hour intensivists staffing could significantly improve ICU outcomes, especially for NT-admission patients in high-acuity, high-volume ICUs with frequent NT admissions.
Collapse
Affiliation(s)
- Ju Min-Jie
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Gu Zhun-Yong
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Han Yan
- Department of General Medical Practice, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Liu Yu-Jing
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - He Hong-Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Liu Yi-Mei
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Tu Guo-Wei
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Luo Jian-Feng
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, People's Republic of China
| | - Zhu Du-Ming
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Luo Zhe
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| |
Collapse
|
49
|
Madrigal V, Walter JK, Sachs E, Himebauch AS, Kubis S, Feudtner C. Pediatric continuity care intensivist: A randomized controlled trial. Contemp Clin Trials 2019; 76:72-78. [PMID: 30468772 DOI: 10.1016/j.cct.2018.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Long-stay critically ill patients in the Pediatric Intensive Care Unit (PICU) may be at risk for inconsistencies in treatment plan, delay in plan progression, and patient/family dissatisfaction with communication. This article describes the development and evaluation of an intervention designed to improve continuity and communication delivered by continuity PICU attendings. METHODS AND ANALYSIS A randomized controlled trial of an intervention in one PICU that was randomized at the patient level. Eligible patients and their parents included those admitted to the PICU for longer than one week and were anticipated to remain for an additional 7 days. The intervention, a Continuity Care Intensivist (CCI), included early assignment of a continuity attending (separate from a regularly scheduled service attending), standardization of the continuity role to ensure consistent team and family contact and facilitate timely decision making, and enhancement of CCI communication skills. The outcomes evaluated were 1) patient PICU length of stay, ventilator-dependent days, and hospital acquired infections, 2) parental mood and satisfaction with PICU communication, and 3) intensivist perception of acceptability of intervention. Intention to treat analysis will be completed using multivariable linear regression to determine the impact of the intervention on outcomes. Lessons have been learned about the appropriate enrollment criteria for patients to allow for impact of continuity attending, frequent prognostic uncertainty in determining which patients will become longer stay in the PICU, and the difficulty of achieving timely initial contact of continuity attending with patients given the CCI's other commitments.
Collapse
Affiliation(s)
- Vanessa Madrigal
- Children's National Health System, Washington, DC, United States
| | - Jennifer K Walter
- Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Emily Sachs
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Adam S Himebauch
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sherri Kubis
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
50
|
Hosseinian L, Reich DL. Commentary: What makes a cardiac surgical intensive care unit safe after midnight? J Thorac Cardiovasc Surg 2018; 157:1543-1544. [PMID: 30448164 DOI: 10.1016/j.jtcvs.2018.09.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Leila Hosseinian
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David L Reich
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; The Mount Sinai Hospital, New York, NY.
| |
Collapse
|