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Grissom CK, Holubkov R, Carpenter L, Hanna B, Jacobs JR, Jones C, Knighton AJ, Leither L, Lisonbee D, Peltan ID, Winberg C, Wolfe D, Srivastava R. Implementation of coordinated spontaneous awakening and breathing trials using telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH): a type II hybrid effectiveness-implementation cluster-randomized trial. Implement Sci 2023; 18:45. [PMID: 37735443 PMCID: PMC10515061 DOI: 10.1186/s13012-023-01303-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality. Coordination of SATs and SBTs is difficult with substantial implementation barriers due to difficult-to-execute sequencing between nurses and respiratory therapists. Telehealth-enabled remote care has the potential to overcome these barriers and improve coordinated SAT and SBT adherence by enabling proactive high-risk patient monitoring, surveillance, and real-time assistance to frontline ICU teams. METHODS The telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH) study will determine whether adding a telehealth augmented real-time audit and feedback to a usual supervisor-led audit and feedback intervention will yield higher coordinated SAT and SBT adherence and more ventilator-free days in mechanically ventilated patients than a usual supervisor-led audit and feedback intervention alone in a type II hybrid effectiveness-implementation cluster-randomized clinical trial in 12 Intermountain Health hospitals with 15 ICUs. In the active comparator control group (six hospitals), the only intervention is the usual supervisor-led audit and feedback implementation. The telehealth-enabled support (TEACH) intervention in six hospitals adds real-time identification of patients eligible for a coordinated SAT and SBT and consultative input from telehealth respiratory therapists, nurses, and physicians to the bedside clinicians to promote adherence including real-time assistance with execution. All intubated and mechanically ventilated patients ≥ 16 years of age are eligible for enrollment except for patients who die on the day of intubation or have preexisting brain death. Based on preliminary power analyses, we plan a 36-month intervention period that includes a 90-day run-in period. Estimated enrollment in the final analysis is up to 9900 mechanically ventilated patients over 33 months. DISCUSSION The TEACH study will enhance implementation science by providing insight into how a telehealth intervention augmenting a usual audit and feedback implementation may improve adherence to coordinated SAT and SBT and increase ventilator-free days. TRIAL REGISTRATION Clinicaltrials.gov, NCT05141396 , registered 12/02/2021.
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Affiliation(s)
- Colin K Grissom
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA.
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA.
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA.
| | - Richard Holubkov
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Lori Carpenter
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Bridgett Hanna
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Jason R Jacobs
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Christopher Jones
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA
| | - Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Lindsay Leither
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Dee Lisonbee
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Carrie Winberg
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Doug Wolfe
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
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Kahn JM, Minturn JS, Riman KA, Bukowski LA, Davis BS. Characterizing intensive care unit rounding teams using meta-data from the electronic health record. J Crit Care 2022; 72:154143. [PMID: 36084377 DOI: 10.1016/j.jcrc.2022.154143] [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: 06/15/2022] [Revised: 08/08/2022] [Accepted: 08/22/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Teamwork is an important determinant of outcomes in the intensive care unit (ICU), yet the nature of individual ICU teams remains poorly understood. We examined whether meta-data in the form of digital signatures in the electronic health record (EHR) could be used to identify and characterize ICU teams. METHODS We analyzed EHR data from 27 ICUs over one year. We linked intensivist physicians, nurses, and respiratory therapists to individual patients based on selected EHR meta-data. We then characterized ICU teams by their members' overall past experience and shared past experience; and used network analysis to characterize ICUs by their network's density and centralization. RESULTS We identified 2327 unique providers and 30,892 unique care teams. Teams varied based on their average team member experience (median and total range: 262.2 shifts, 9.0-706.3) and average shared experience (median and total range: 13.2 shared shifts, 1.0-99.3). ICUs varied based on their network's density (median and total range: 0.12, 0.07-0.23), degree centralization (0.50, 0.35-0.65) and closeness centralization (0.45, 0.11-0.60). In a regression analysis, this variation was only partially explained by readily observable ICU characteristics. CONCLUSIONS EHR meta-data can assist in the characterization of ICU teams, potentially providing novel insight into strategies to measure and improve team function in critical care.
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Affiliation(s)
- Jeremy M Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Health Policy & Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA.
| | - John S Minturn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kathryn A Riman
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Leigh A Bukowski
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Billie S Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Guinemer C, Boeker M, Fürstenau D, Poncette AS, Weiss B, Mörgeli R, Balzer F. Telemedicine in Intensive Care Units: Scoping Review. J Med Internet Res 2021; 23:e32264. [PMID: 34730547 PMCID: PMC8600441 DOI: 10.2196/32264] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/03/2021] [Accepted: 09/18/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The role of telemedicine in intensive care has been increasing steadily. Tele-intensive care unit (ICU) interventions are varied and can be used in different levels of treatment, often with direct implications for the intensive care processes. Although a substantial body of primary and secondary literature has been published on the topic, there is a need for broadening the understanding of the organizational factors influencing the effectiveness of telemedical interventions in the ICU. OBJECTIVE This scoping review aims to provide a map of existing evidence on tele-ICU interventions, focusing on the analysis of the implementation context and identifying areas for further technological research. METHODS A research protocol outlining the method has been published in JMIR Research Protocols. This review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A core research team was assembled to provide feedback and discuss findings. RESULTS A total of 3019 results were retrieved. After screening, 25 studies were included in the final analysis. We were able to characterize the context of tele-ICU studies and identify three use cases for tele-ICU interventions. The first use case is extending coverage, which describes interventions aimed at extending the availability of intensive care capabilities. The second use case is improving compliance, which includes interventions targeted at improving patient safety, intensive care best practices, and quality of care. The third use case, facilitating transfer, describes telemedicine interventions targeted toward the management of patient transfers to or from the ICU. CONCLUSIONS The benefits of tele-ICU interventions have been well documented for centralized systems aimed at extending critical care capabilities in a community setting and improving care compliance in tertiary hospitals. No strong evidence has been found on the reduction of patient transfers following tele-ICU intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/19695.
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Affiliation(s)
- Camille Guinemer
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Boeker
- Intelligence and Informatics in Medicine, Medical Center rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Daniel Fürstenau
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Digitalization, Copenhagen Business School, Copenhagen, Denmark
| | - Akira-Sebastian Poncette
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Björn Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Rudolf Mörgeli
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Abstract
Rationale: Psychological safety is the condition by which members of an organization feel safe to voice concerns and take risks. Although psychological safety is an important determinant of team performance, little is known about its role in the intensive care unit (ICU). Objectives: To identify the factors associated with psychological safety and the potential influence of psychological safety on team performance in critical care. Methods: We performed daily surveys of healthcare providers in 12 ICUs within an integrated health system over a 2-week period. Survey domains included psychological safety, leader familiarity, leader inclusiveness, role clarity, job strain, and teamwork. These data were linked to daily performance on lung-protective ventilation and spontaneous breathing trials. We used regression models to examine the antecedents of psychological safety as well as the influence of psychological safety on both perceived teamwork and actual performance. Results: We received 553 responses from 270 unique providers. At the individual provider level, higher leader inclusiveness (adjusted β = 0.32; 95% confidence interval [CI], 0.24 to 0.41) and lower job strain (adjusted β = -0.07, 95% CI, -0.13 to -0.02) were independently associated with greater psychological safety. Higher psychological safety was independently associated with greater perception of teamwork (adjusted β = 0.30; 95% CI, 0.25 to 0.36). There was no association between team psychological safety and performance on either spontaneous breathing trials (incident rate ratio for each 1-unit change in team psychological safety, 0.85; 95% CI, 0.81 to 1.10) or lung-protective ventilation (incident rate ratio, 0.77; 95% CI, 0.57 to 1.04). Conclusions: Psychological safety is associated with several modifiable factors in the ICU but is not associated with actual use of evidence-based practices.
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Rangappa P, Rao K, Chandra T, Karanth S, Chacko J. Tele-medicine, tele-rounds, and tele-intensive care unit in the COVID-19 pandemic. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2021. [DOI: 10.4103/injms.injms_100_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Telemedicine in the intensive care unit: A vehicle to improve quality of care? J Crit Care 2020; 61:241-246. [PMID: 33220577 DOI: 10.1016/j.jcrc.2020.09.036] [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] [Received: 06/12/2020] [Revised: 09/03/2020] [Accepted: 09/17/2020] [Indexed: 11/22/2022]
Abstract
The high demand for intensive care, which is predicted to further increase in the future, is contrasted by a shortage of trained intensivists and specialized nurses. Telemedicine has been heralded as a promising solution. Yet, there is considerable heterogeneity in tele-critical care when it comes to measurable effects. However, the focus has been on telemedical solutions substituting on-site intensivist functions, and outcome measures have primarily been mortality and length of stay. In a new model of telemedicine for the ICU, telemedicine could be used to increase adherence to best practice guidelines and indicators of process quality. Further, indicators of process quality, functional outcomes and quality of life measures should be incorporated in the evaluation of outcomes, as patients frequently value those higher than mere survival.
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Angriman F, Pinto R, Friedrich JO, Ferguson ND, Rubenfeld G, Amaral ACKB. Compliance With Evidence-Based Processes of Care After Transitions Between Staff Intensivists. Crit Care Med 2020; 48:e227-e232. [PMID: 31913986 DOI: 10.1097/ccm.0000000000004201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES We sought to evaluate the impact of transitions of care among staff intensivists on the compliance with evidence-based processes of care. DESIGN Cohort study using data from the Toronto Intensive Care Observational Registry. SETTING Seven academic ICUs in Toronto, Ontario. PATIENTS Critically ill mechanically ventilated adult patients. INTERVENTIONS We explored the effects of the weekly transition of care among staff intensivists on compliance with three evidence-based processes of care (spontaneous breathing trials, lung-protective ventilation, and neuromuscular blocking agents). Two practices that are less guided by evidence (early discontinuation of antibiotics and extubation attempts) served as positive controls. We conducted the analysis using generalized estimating equations to account for clustering at the patient level. MEASUREMENTS AND MAIN RESULTS The cohort consisted of 10,570 patients admitted between June 2014 and August 2018. Compliance varied for each practice (63.6%, 42.5%, and 21.1% for lung-protective ventilation, spontaneous breathing trials, and neuromuscular blockade, respectively). There was no effect of transitions of care on compliance with spontaneous breathing trials (odds ratio, 1.00; 95% CI, 0.95-1.07), lung-protective ventilation (odds ratio, 1.07, 95% CI, 0.90-1.26), or neuromuscular blockade use (odds ratio, 0.95; 95% CI, 0.75-1.20). However, early antibiotic discontinuation was more likely (odds ratio, 1.23; 95% CI, 1.06-1.42) and extubation attempts were less frequent (odds ratio, 0.77; 95% CI, 0.65-0.93) after a transition of care. CONCLUSIONS We observed no significant impact of transitions of care between individual staff physicians on evidence-based processes of care for mechanically ventilated adult patients. However, transitions were associated with a lower likelihood of extubation and higher odds of earlier discontinuation of antibiotics.
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada.,Department of Critical Care and Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Gordon Rubenfeld
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
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Do What You Can, With What You Have, Where You Are. J Trauma Nurs 2020; 27:3-5. [PMID: 31895312 DOI: 10.1097/jtn.0000000000000475] [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]
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9
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Lilly CM, Mickelson JT. Evolution of the Intensive Care Unit Telemedicine Value Proposition. Crit Care Clin 2019; 35:463-477. [PMID: 31076046 DOI: 10.1016/j.ccc.2019.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Advances in clinical information sciences, telecommunication technologies, electronic health records, early warning systems, automated acuity assessment, and clinician communication support systems have allowed current-generation intensive care (ICU) telemedicine systems to address the inefficiencies of the failed advice-upon-request ICU telemedicine model. Value is related to the ability of health care systems to leverage ICU telemedicine resources to provide care. Local financial benefits of ICU telemedicine program implementation depend on changing behavior to better focus on activities that reduce the duration of critical illness and length of stay.
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Affiliation(s)
- Craig M Lilly
- Department of Medicine, University of Massachusetts Medical School, Graduate School of Biomedical Sciences, UMass Memorial Health Care, Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA; Department of Anesthesiology, and Surgery, Clinical and Population Health Research Program, University of Massachusetts Medical School, Graduate School of Biomedical Sciences, UMass Memorial Health Care, Memorial Medical Center, 281 Lincoln Street, Worcester, MA 01605, USA.
| | - Jared T Mickelson
- Department of Medicine, University of Massachusetts Medical School, Graduate School of Biomedical Sciences, UMass Memorial Health Care, Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
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Abstract
Telemedicine coverage of intensive care units is an organizational innovation that has been touted as a means to improve access to and quality of critical care. The purpose of this narrative review is to discuss the different organizational models of intensive care unit telemedicine and factors that have influenced its adoption and to review the existing literature to consider whether it has lived up to its promise. We conclude by suggesting future directions to fill in some of the existing gaps in the literature.
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Practice, But Verify: A Novel Method to Assess Compliance With Lung Protective Ventilation Using Electronic Health Record Data. Crit Care Med 2019; 47:131-133. [PMID: 30557246 DOI: 10.1097/ccm.0000000000003490] [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]
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Abstract
Intensive care unit (ICU) telemedicine is an established entity that has the ability to not only improve the effectiveness, efficiency, and safety of critical care, but to also serve as a tool to combat staffing shortages and resource-limited environments. Several areas for future innovation exist within the field, including the use of advanced practice providers, robust inclusion in medical education, and concurrent application of advanced machine learning. The globalization of critical care services will also likely be predominantly delivered by ICU telemedicine. Limitations faced by the field include technical issues, financial concerns, and organizational elements.
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Intensive Care Unit Telemedicine in the Era of Big Data, Artificial Intelligence, and Computer Clinical Decision Support Systems. Crit Care Clin 2019; 35:483-495. [PMID: 31076048 DOI: 10.1016/j.ccc.2019.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article examines the history of the telemedicine intensive care unit (tele-ICU), the current state of clinical decision support systems (CDSS) in the tele-ICU, applications of machine learning (ML) algorithms to critical care, and opportunities to integrate ML with tele-ICU CDSS. The enormous quantities of data generated by tele-ICU systems is a major driver in the development of the large, comprehensive, heterogeneous, and granular data sets necessary to develop generalizable ML CDSS algorithms, and deidentification of these data sets expands opportunities for ML CDSS research.
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Udeh C, Udeh B, Rahman N, Canfield C, Campbell J, Hata JS. Telemedicine/Virtual ICU: Where Are We and Where Are We Going? Methodist Debakey Cardiovasc J 2018; 14:126-133. [PMID: 29977469 DOI: 10.14797/mdcj-14-2-126] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Intensive care unit telemedicine (tele-ICU) is technology enabled care delivered from off-site locations that was developed to address the increasing complexity of patients and insufficient supply of intensivists. Although tele-ICU deployment is increasing, it continues to cover only a small proportion of ICU patients. This is primarily due to expense, with first-year costs exceeding $50,000 per bed. Meta-analyses of outcomes indicate survival benefits and quality improvements, albeit with significant heterogeneity. Depending on the context, a wide range of estimated incremental cost-effectiveness ratios reflects variable effects on cost and outcomes, such as mortality or length of stay. Tele-ICUs may fit within a hybrid model of care to complement high-intensity ICU staff coverage. However, more research is required to foster consensus and determine best practices. This review summarizes data on tele-ICU structure, operations, outcomes, and costs. Evidence was extracted from meta-analyses, with secondary data from Cleveland Clinic's tele-ICU experience.
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Kruse CS, Beane A. Health Information Technology Continues to Show Positive Effect on Medical Outcomes: Systematic Review. J Med Internet Res 2018; 20:e41. [PMID: 29402759 PMCID: PMC5818676 DOI: 10.2196/jmir.8793] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 09/17/2017] [Accepted: 10/04/2017] [Indexed: 01/08/2023] Open
Abstract
Background Health information technology (HIT) has been introduced into the health care industry since the 1960s when mainframes assisted with financial transactions, but questions remained about HIT’s contribution to medical outcomes. Several systematic reviews since the 1990s have focused on this relationship. This review updates the literature. Objective The purpose of this review was to analyze the current literature for the impact of HIT on medical outcomes. We hypothesized that there is a positive association between the adoption of HIT and medical outcomes. Methods We queried the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medical Literature Analysis and Retrieval System Online (MEDLINE) by PubMed databases for peer-reviewed publications in the last 5 years that defined an HIT intervention and an effect on medical outcomes in terms of efficiency or effectiveness. We structured the review from the Primary Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and we conducted the review in accordance with the Assessment for Multiple Systematic Reviews (AMSTAR). Results We narrowed our search from 3636 papers to 37 for final analysis. At least one improved medical outcome as a result of HIT adoption was identified in 81% (25/37) of research studies that met inclusion criteria, thus strongly supporting our hypothesis. No statistical difference in outcomes was identified as a result of HIT in 19% of included studies. Twelve categories of HIT and three categories of outcomes occurred 38 and 65 times, respectively. Conclusions A strong majority of the literature shows positive effects of HIT on the effectiveness of medical outcomes, which positively supports efforts that prepare for stage 3 of meaningful use. This aligns with previous reviews in other time frames.
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Affiliation(s)
- Clemens Scott Kruse
- School of Health Administration, Texas State University, San Marcos, TX, United States
| | - Amanda Beane
- School of Health Administration, Texas State University, San Marcos, TX, United States
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Takiguchi C, Yatomi Y, Inoue T. Development of the Nurses' Care Coordination Competency Scale for mechanically ventilated patients in critical care settings in Japan: Part 2 Validation of the scale. Intensive Crit Care Nurs 2017; 43:30-38. [PMID: 28911833 DOI: 10.1016/j.iccn.2017.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 07/26/2017] [Accepted: 08/05/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To confirm the validity and reliability of the nurses' care coordination competency draft scale for mechanically ventilated patients in Japan. DESIGN/METHOD In this cross sectional observational study, a draft scale measuring care coordination was distributed to 2189 nurses from 73 intensive care units in Japan from February-March 2016. Based on the valid 887 responses, we examined construct validity including structural validity (exploratory and confirmatory factor analysis), convergent and discriminant validity and internal consistency reliability. SETTINGS 73 Intensive care units. RESULTS Exploratory factor analyses yielded four factors with 22 items: 1) promoting team cohesion, 2) understanding care coordination needs, 3) aggregating and disseminating information, 4) devising and clearly articulating the care vision. The four-factor model was confirmed using a confirmatory factor analysis (confirmatory fit index=0.942, root mean square error of approximation=0.062). Scale scores positively correlated with team leadership and clearly identified and discriminated nurses' attributes. Cronbach's alpha coefficient for each subscale was between 0.812 and 0.890, and 0.947 for the total scale. CONCLUSIONS The Nurses' Care Coordination Competency Scale with four factors and 22 items had sufficient validity and reliability. The scale could make care coordination visible in nursing practice. Future research on the relationship between this scale and patient outcomes is needed.
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Affiliation(s)
- Chie Takiguchi
- Toho University, Miyama 2-2-1, Funabashi, Chiba 274-8510, Japan
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Barbash IJ, Pike F, Gunn SR, Seymour CW, Kahn JM. Effects of Physician-targeted Pay for Performance on Use of Spontaneous Breathing Trials in Mechanically Ventilated Patients. Am J Respir Crit Care Med 2017; 196:56-63. [PMID: 27936874 PMCID: PMC5519961 DOI: 10.1164/rccm.201607-1505oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/06/2016] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Pay for performance is an increasingly common quality improvement strategy despite the absence of robust supporting evidence. OBJECTIVES To determine the impact of a financial incentive program rewarding physicians for the completion of daily spontaneous breathing trials (SBTs) in three academic hospitals. METHODS We compared data from mechanically ventilated patients from 6 months before to 2 years after introduction of a financial incentive program that provided annual payments to critical care physicians contingent on unit-level SBT completion rates. We used Poisson regression to compare the frequency of days on which SBTs were completed among eligible patients and days on which patients were excluded from SBT eligibility among all mechanically ventilated patients. We used multivariate regression to compare risk-adjusted duration of mechanical ventilation and in-hospital mortality. MEASUREMENTS AND MAIN RESULTS The cohort included 7,291 mechanically ventilated patients with 75,621 ventilator days. Baseline daily SBT rates were 96.8% (hospital A), 16.4% (hospital B), and 74.7% (hospital C). In hospital A, with the best baseline performance, there was no change in SBT rates, exclusion rates, or duration of mechanical ventilation across time periods. In hospitals B and C, with lower SBT completion rates at baseline, there was an increase in daily SBT completion rates and a concomitant increase in exclusions from eligibility. Duration of mechanical ventilation decreased in hospital C but not in hospital B. Mortality was unchanged for all hospitals. CONCLUSIONS In hospitals with low baseline SBT completion, physician-targeted financial incentives were associated with increased SBT rates driven in part by increased exclusion rates, without consistent improvements in outcome.
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Affiliation(s)
- Ian J. Barbash
- Division of Pulmonary, Allergy, and Critical Care Medicine and
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Francis Pike
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Scott R. Gunn
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Christopher W. Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Jeremy M. Kahn
- Division of Pulmonary, Allergy, and Critical Care Medicine and
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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Roberts RJ, Alhammad AM, Crossley L, Anketell E, Wood L, Schumaker G, Garpestad E, Devlin JW. A survey of critical care nurses' practices and perceptions surrounding early intravenous antibiotic initiation during septic shock. Intensive Crit Care Nurs 2017; 41:90-97. [PMID: 28363592 DOI: 10.1016/j.iccn.2017.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 01/07/2017] [Accepted: 02/10/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Delays in antibiotic administration after severe sepsis recognition increases mortality. While physician and pharmacy-related barriers to early antibiotic initiation have been well evaluated, those factors that affect the speed by which critical care nurses working in either the emergency department or the intensive care unit setting initiate antibiotic therapy remains poorly characterized. AIM To evaluate the knowledge, practices and perceptions of critical care nurses regarding antibiotic initiation in patients with newly recognised septic shock. METHODS A validated survey was distributed to 122 critical care nurses at one 320-bed academic institution with a sepsis protocol advocating intravenous(IV) antibiotic initiation within 1hour of shock recognition. RESULTS Among 100 (82%) critical care nurses responding, nearly all (98%) knew of the existence of the sepsis protocol. However, many critical care nurses stated they would optimise blood pressure [with either fluid (38%) or both fluid and a vasopressor (23%)] before antibiotic initiation. Communicated barriers to rapid antibiotic initiation included: excessive patient workload (74%), lack of awareness IV antibiotic(s) ordered (57%) or delivered (69%), need for administration of multiple non-antibiotic IV medications (54%) and no IV access (51%). CONCLUSIONS Multiple nurse-related factors influence IV antibiotic(s) initiation speed and should be incorporated into sepsis quality improvement efforts.
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Affiliation(s)
- Russel J Roberts
- Department of Pharmacy, Tufts Medical Center, 800 Washington Street, Box 420, Boston, MA 02111, USA; School of Pharmacy, Northeastern University, 360 Huntington Ave, R218 TF, Boston, MA 02115, USA.
| | - Abdullah M Alhammad
- Department of Pharmacy, King Khalid University Hospital, P.O. Box 2457, Riyadh 11451, Saudi Arabia.
| | | | - Eric Anketell
- Department of Nursing, Tufts Medical Center, Boston, MA, USA.
| | - LeeAnn Wood
- Department of Nursing, Tufts Medical Center, Boston, MA, USA.
| | - Greg Schumaker
- Division of Pulmonary, Critical Care and Sleep Medicine, USA.
| | - Erik Garpestad
- Division of Pulmonary, Critical Care and Sleep Medicine, USA.
| | - John W Devlin
- School of Pharmacy, Northeastern University, 360 Huntington Ave, R218 TF, Boston, MA 02115, USA; Division of Pulmonary, Critical Care and Sleep Medicine, USA.
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19
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Darby JL, Kahn JM. The Use of Health Information Technology to Improve Sepsis Care. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2017. [DOI: 10.1007/978-3-319-51908-1_39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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20
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Lilly CM, Motzkus C, Rincon T, Cody SE, Landry K, Irwin RS. ICU Telemedicine Program Financial Outcomes. Chest 2016; 151:286-297. [PMID: 27932050 DOI: 10.1016/j.chest.2016.11.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 10/14/2016] [Accepted: 11/15/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND ICU telemedicine improves access to high-quality critical care, has substantial costs, and can change financial outcomes. Detailed information about financial outcomes and their trends over time following ICU telemedicine implementation and after the addition of logistic center function has not been published to our knowledge. METHODS Primary data were collected for consecutive adult patients of a single academic medical center. We compared clinical and financial outcomes across three groups that differed regarding telemedicine support: a group without ICU telemedicine support (pre-ICU intervention group), a group with ICU telemedicine support (ICU telemedicine group), and an ICU telemedicine group with added logistic center functions and support for quality-care standardization (logistic center group). The primary outcome was annual direct contribution margin defined as aggregated annual case revenue minus annual case direct costs (including operating costs of ICU telemedicine and its related programs). All monetary values were adjusted to 2015 US dollars using Producer Price Index for Health-Care Facilities. RESULTS Annual case volume increased from 4,752 (pre-ICU telemedicine) to 5,735 (ICU telemedicine) and 6,581 (logistic center). The annual direct contribution margin improved from $7,921,584 (pre-ICU telemedicine) to $37,668,512 (ICU telemedicine) to $60,586,397 (logistic center) due to increased case volume, higher case revenue relative to direct costs, and shorter length of stay. CONCLUSIONS The ability of properly modified ICU telemedicine programs to increase case volume and access to high-quality critical care with improved annual direct contribution margins suggests that there is a financial argument to encourage the wider adoption of ICU telemedicine.
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Affiliation(s)
- Craig M Lilly
- Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA; Department of Anesthesiology and Surgery, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA; Clinical and Population Health Research Program, UMass Memorial Medical Center, Worcester, MA; Graduate School of Biomedical Sciences, UMass Memorial Medical Center, Worcester, MA.
| | - Christine Motzkus
- Clinical and Population Health Research Program, UMass Memorial Medical Center, Worcester, MA
| | - Teresa Rincon
- Department of Nursing, UMass Memorial Medical Center, Worcester, MA
| | - Shawn E Cody
- UMass Memorial Health Care, UMass Memorial Medical Center, Worcester, MA; Department of Nursing, UMass Memorial Medical Center, Worcester, MA
| | - Karen Landry
- UMass Memorial Health Care, UMass Memorial Medical Center, Worcester, MA
| | - Richard S Irwin
- Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA; Graduate School of Nursing Sciences, UMass Memorial Medical Center, Worcester, MA
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21
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Becker C, Frishman WH, Scurlock C. Telemedicine and Tele-ICU: The Evolution and Differentiation of a New Medical Field. Am J Med 2016; 129:e333-e334. [PMID: 27576079 DOI: 10.1016/j.amjmed.2016.05.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Christian Becker
- Center for Telemedicine & eHealth, Westchester Medical Center, Valhalla, NY; Department of Medicine, New York Medical College, Valhalla.
| | | | - Corey Scurlock
- Center for Telemedicine & eHealth, Westchester Medical Center, Valhalla, NY
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22
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Arabi YM, Schultz MJ, Salluh JIF. Intensive Care Medicine in 2050: global perspectives. Intensive Care Med 2016; 43:1695-1699. [PMID: 27900405 DOI: 10.1007/s00134-016-4631-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Yaseen M Arabi
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), PO Box 22490, Riyadh, 11426, Saudi Arabia. .,King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia.
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
| | - Jorge I F Salluh
- Critical Care department, D'OR Institute for Research and Education, Rio De Janeiro, Brazil.,Post-Graduate Program Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
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Seaman JB, Evans AC, Sciulli AM, Barnato AE, Sereika SM, Happ MB. Abstracting ICU Nursing Care Quality Data From the Electronic Health Record. West J Nurs Res 2016; 39:1271-1288. [PMID: 27605024 DOI: 10.1177/0193945916665814] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen's kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1,440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.
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Development of Process Control Methodology for Tracking the Quality and Safety of Pain, Agitation, and Sedation Management in Critical Care Units. Crit Care Med 2016; 44:564-74. [PMID: 26901544 DOI: 10.1097/ccm.0000000000001463] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. DESIGN A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. SETTING Eight Scottish ICUs over a 12-month period. PATIENTS Mechanically ventilated patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman ρ = 0.75) and were reliable in clinician-clinician (weighted kappa; κ = 0.66) and clinician-researcher (κ = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale (ρ = 0.24) and was reliable in clinician-clinician (κ = 0.58) and clinician-researcher (κ = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale (ρ = 0.54), and reliability in clinician-clinician (κ = 0.29) and clinician-researcher (κ = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. CONCLUSIONS Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time.
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Abstract
BACKGROUND Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain. OBJECTIVES To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals. RESEARCH DESIGN We performed a multicenter retrospective case-control study using 2001-2010 Medicare claims data linked to a national survey identifying US hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 nonadopting hospitals (controls) based on size, case-mix, and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach. RESULTS A total of 132 adopting case hospitals were matched to 389 similar nonadopting control hospitals. The preadoption and postadoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%, P=0.07) and control hospitals (23.5% vs. 23.7%, P<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios=0.96; 95% CI, 0.95-0.98; P<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios=1.01; interquartile range, 0.85-1.12; range, 0.45-2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions postadoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (P<0.001) and be located in urban areas (P=0.04) compared with other hospitals. CONCLUSIONS Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions.
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Harrison AM, Gajic O, Pickering BW, Herasevich V. Development and Implementation of Sepsis Alert Systems. Clin Chest Med 2016; 37:219-29. [PMID: 27229639 DOI: 10.1016/j.ccm.2016.01.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Development and implementation of sepsis alert systems is challenging, particularly outside the monitored intensive care unit (ICU) setting. Barriers to wider use of sepsis alerts include evolving clinical definitions of sepsis, information overload, and alert fatigue, due to suboptimal alert performance. Outside the ICU, barriers include differences in health care delivery models, charting behaviors, and availability of electronic data. Current evidence does not support routine use of sepsis alert systems in clinical practice. Continuous improvement in the afferent and efferent aspects will help translate theoretic advantages into measurable patient benefit.
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Affiliation(s)
- Andrew M Harrison
- Medical Scientist Training Program, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Ognjen Gajic
- Division of Pulmonology and Critical Care Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Brian W Pickering
- Department of Anesthesiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Vitaly Herasevich
- Department of Anesthesiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Abstract
OBJECTIVE To review how disability can develop in older adults with critical illness and to explore ways to reduce long-term disability following critical illness. DATA SOURCES We searched PubMed, CINAHL, Web of Science and Google Scholar for studies reporting disability outcomes (i.e., activities of daily living, instrumental activities of daily living, and mobility activities) and/or cognitive outcomes among patients treated in an ICU who were 65 years or older. We also reviewed the bibliographies of relevant citations to identify additional citations. STUDY SELECTION We identified 19 studies evaluating disability outcomes in critically ill patients who were 65 years and older. DATA EXTRACTION Descriptive epidemiologic data on disability after critical illness. DATA SYNTHESIS Newly acquired disability in activities of daily living, instrumental activities of daily living, and mobility activities was commonplace among older adults who survived a critical illness. Incident dementia and less severe cognitive impairment were also highly prevalent. Factors related to the acute critical illness, ICU practices, such as heavy sedation, physical restraints, and immobility, as well as aging physiology, and coexisting geriatric conditions can combine to result in these poor outcomes. CONCLUSIONS Older adults who survive critical illness have physical and cognitive declines resulting in disability at greater rates than hospitalized, noncritically ill and community dwelling older adults. Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs.
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Abstract
During the last 15 years, critical care services provided via telemedicine have expanded to now be incorporated into the care of 13% of patients in intensive care units (ICUs) in the United States. A response to shortfalls in the availability of critical care-trained providers has evolved into integrated programs of ICU care with contributions to improved outcomes through proactive management, population oversight, and standardization of care processes. The most impactful characteristics of successful ICU telemedicine programs are now better understood with more than a decade of national experience and the accrued benefits to health care systems.
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Affiliation(s)
- Steven A Fuhrman
- Division of Pulmonary and Critical Care Medicine, Sentara Norfolk General Hospital, Sentara eICU, Sentara Medical Group, Raleigh 306, Norfolk, VA 23507, USA
| | - Craig M Lilly
- Department of Medicine, UMass Memorial Medical Center, University of Massachusetts Medical School, 281 Lincoln Street, Worcester, MA 01605, USA; Department of Anesthesiology, UMass Memorial Medical Center, University of Massachusetts Medical School, 281 Lincoln Street, Worcester, MA 01605, USA; Department of Surgery, UMass Memorial Medical Center, University of Massachusetts Medical School, 281 Lincoln Street, Worcester, MA 01605, USA.
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Kahn JM, Rubenfeld GD. The myth of the workforce crisis. Why the United States does not need more intensivist physicians. Am J Respir Crit Care Med 2015; 191:128-34. [PMID: 25474081 DOI: 10.1164/rccm.201408-1477cp] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intensivist physician staffing is associated with lower mortality in the intensive care unit (ICU), yet many ICUs are not staffed by trained intensivists. This gap has led to a number of proposals intended to increase the intensivist supply in the United States. In this perspective we argue that such efforts would be both ineffective and ill-advised. Because many ICU patients are not critically ill, workforce models that base demand projections on ICU admission rather than true critical illness substantially overstate the workforce gap. Even in the presence of a workforce gap, training new intensivists would not place them in hospitals where they are needed most, would not mitigate the shortage of nonphysician critical care providers, and would require a unrealistic increase in spending on physician training. In addition, efforts to train more intensivists require us to prioritize intensive care over other specialties that are also in short supply, without clear justification for why intensivists are more important. Rather than continuing an unwarranted push to increase the intensivist supply, we suggest alternative workforce policies that emphasize novel interprofessional care models (to improve ICU quality in the absence of intensivists) combined with limitations on the future growth of ICU beds (to reduce demand through implicit rationing of care). These policies offer opportunities to reduce the mismatch between critical care supply and demand without an unnecessary expansion of the intensivist supply.
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Affiliation(s)
- Jeremy M Kahn
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Bassett R, Adams KM, Danesh V, Groat PM, Haugen A, Kiewel A, Small C, Van-Leuven M, Venus S, Ely EW. Rethinking critical care: decreasing sedation, increasing delirium monitoring, and increasing patient mobility. Jt Comm J Qual Patient Saf 2015; 41:62-74. [PMID: 25976892 PMCID: PMC4718659 DOI: 10.1016/s1553-7250(15)41010-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sedation management, delirium monitoring, and mobility programs have been addressed in evidence-based critical care guidelines and care bundles, yet implementation in the ICU remains variable. As critically ill patients occupy higher percentages of hospital beds in the United States and beyond, it is increasingly important to determine mechanisms to deliver better care. The Institute for Healthcare Improvement's Rethinking Critical Care (IHI-RCC) program was established to reduce harm of critically ill patients by decreasing sedation, increasing monitoring and management of delirium, and increasing patient mobility. Case studies of a convenience sample of five participating hospitals/health systems chosen in advance of the determination of their clinical outcomes are presented in terms of how they got started and process improvements in sedation management, delirium management, and mobility. METHODS The IHI-RCC program involved one live case study and five iterations of an in-person seminar in a 33-month period (March 2011-November 2013) that emphasized interdisciplinary teamwork and culture change. RESULTS Qualitative descriptions of the changes tested at each of the five case study sites demonstrate improvements in teamwork, processes, and reliability of daily work. Improvement in ICU length of stay and length of stay on the ventilator between the pre- and postimplementation periods varied from slight to substantial. CONCLUSION Changing critical care practices requires an interdisciplinary approach addressing cultural, psychological, and practical issues. The key lessons of the IHI-RCC program are as follows: the importance of testing changes on a small scale, feeding back data regularly and providing sufficient education, and building will through seeing the work in action.
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