Critical Care Delivery: The Importance of Process of Care and ICU Structure to Improved Outcomes: An Update From the American College of Critical Care Medicine Task Force on Models of Critical Care

Pain management of adult sedated and ventilated patients in the intensive care units: A survey with free text responses

BACKGROUND

Pain management of sedated and ventilated patients in intensive care units lacks consistency.

OBJECTIVES

To investigate nurses' training, governance, practices, knowledge and attitudes relating to pain management in consideration of published guidelines and explore nurses' perspectives.

METHODS

A survey design, using an online questionnaire with free text responses, was employed. Quantitative and qualitative data from nurses working across different hospitals were collated and saved on Qualtrics platform. Quantitative data were analysed non-parametrically and narrative responses thematically. CROSS and SRQR reporting guidelines were adhered to.

OUTCOME MEASURES

Demographics, training, governance, clinical practice, knowledge, and attitudes.

RESULTS/FINDINGS

108 nurses participated with ninety-two completed surveys analysed. Analgesia was used to complete nursing tasks regardless of comfort needs (n = 49, 53.3 %). Changes in vital signs prompted opioid administration (n = 48, 52.1 %). Choice of analgesia depended on doctor's preference (n = 63, 68.5 %). Non-opioid therapy was administered before opioids (n = 42, 45.7 %). Sedatives were used to alleviate agitation(n = 50,54.3 %). No statistically significant difference in nurses' knowledge existed between hospitals. Weak positive relationship: r = [0.081], p = [0.441] between "knowledge scores" and "years of ICU experience" and weak negative relationship r = [-0.119], p = [0.260] between "knowledge scores" and "hours of clinical practice" was detected. Lack of training, resources, policies, high patient acuity and casual employment were acknowledged barriers to pain management. Two overarching themes emerged from narrative responses: "Pain assessment, where is it?" And "Priorities of critical illness."

CONCLUSION

The study uncovered pain management situation and examined nurses' demographics, training, governance, practices, knowledge and attitudes. Narrative responses highlighted barriers to pain management.

IMPLICATIONS FOR CLINICAL PRACTICE

Health organisations should provide education, institute governance and develop policies to inform pain management. Nurses' role encompasses updating knowledge, adhering to interventions and overcoming biases. This subsequently manifests as improvement in patient outcomes.

Overnight In-House Critical Care Resource Intensivist Improves General Surgery Resident Education

24/7 critical care staffing has become more commonplace, and their impact on resident training must be carefully considered. At our institution, the Critical Care Resource Intensivist (CCRI) model was implemented to provide in-house dedicated faculty responsible solely for the provision of critical care overnight. An anonymous survey was distributed to all general surgery residents to evaluate CCRI's impact on education and autonomy. Descriptive statistics were completed for quantitative data. Qualitative analysis of free text responses was completed to identify consensus themes. Responses from 26 residents demonstrated they associated CCRI with improved resident education, supervision, and patient care, without limiting autonomy. Qualitative analysis yielded 7 themes, reflecting improvements in patient care and safety, progression of care, operations and procedures, improved education, availability, and independence, but noted potential for conflict. Our findings show 24/7 dedicated intensivist staffing can enhance general surgery resident education without limiting autonomy.

Interprofessional Staffing Pattern Clusters in U.S. ICUs

OBJECTIVES

To identify interprofessional staffing pattern clusters used in U.S. ICUs.

DESIGN

Latent class analysis.

SETTING AND PARTICIPANTS

Adult U.S. ICUs.

PATIENTS

None.

INTERVENTIONS

None.

ANALYSIS

We used data from a staffing survey that queried respondents (n = 596 ICUs) on provider (intensivist and nonintensivist), nursing, respiratory therapist, and clinical pharmacist availability and roles. We used latent class analysis to identify clusters describing interprofessional staffing patterns and then compared ICU and hospital characteristics across clusters.

MEASUREMENTS AND MAIN RESULTS

We identified three clusters as optimal. Most ICUs (54.2%) were in cluster 1 ("higher overall staffing") characterized by a higher likelihood of good provider coverage (both intensivist [onsite 24 hr/d] and nonintensivist [orders placed by ICU team exclusively, presence of advanced practice providers, and physicians-in-training]), nursing leadership (presence of charge nurse, nurse educators, and managers), and bedside nursing support (nurses with registered nursing degrees, fewer patients per nurse, and nursing aide availability). One-third (33.7%) were in cluster 2 ("lower intensivist coverage & nursing leadership, higher bedside nursing support") and 12.1% were in cluster 3 ("higher provider coverage & nursing leadership, lower bedside nursing support"). Clinical pharmacists were more common in cluster 1 (99.4%), but present in greater than 85% of all ICUs; respiratory therapists were nearly universal. Cluster 1 ICUs were larger (median 20 beds vs. 15 and 17 in clusters 2 and 3, respectively; p < 0.001), and in larger (> 250 beds: 80.6% vs. 66.1% and 48.5%; p < 0.001), not-for-profit (75.9% vs. 69.4% and 60.3%; p < 0.001) hospitals. Telemedicine use 24 hr/d was more common in cluster 3 units (71.8% vs. 11.7% and 14.1%; p < 0.001).

CONCLUSIONS

More than half of U.S. ICUs had higher staffing overall. Others tended to have either higher provider presence and nursing leadership or higher bedside nursing support, but not both.

Associations of the staffing structure of intensive care units and high care units on in-hospital mortality among patients with sepsis: a cross-sectional study of Japanese nationwide claims data

OBJECTIVE

The objective was to analyse the associations of intensive care unit (ICU) and high care unit (HCU) organisational structure on in-hospital mortality among patients with sepsis in Japan's acute care hospitals.

DESIGN

Multicentre cross-sectional study.

SETTINGS

Patients with sepsis aged ≥18 years who received critical care in acute care hospitals throughout Japan between April 2018 and March 2019 were identified using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB).

INTERVENTIONS

None.

PARTICIPANTS

10 968 patients with sepsis were identified. ICUs were categorised into three groups: type 1 ICUs (fulfilling stringent staffing criteria such as experienced intensivists and high nurse-to-patient ratios), type 2 ICUs (less stringent criteria) and HCUs (least stringent criteria).

PRIMARY OUTCOME MEASURE

The study's primary outcome measure was in-hospital mortality. Cox proportional hazards regression analysis was performed to examine the impact of ICU/HCU groups on in-hospital mortality.

RESULTS

We analysed 2411 patients (178 hospitals) in the type 1 ICU group, 3653 patients (422 hospitals) in the type 2 ICU group and 4904 patients (521 hospitals) in the HCU group. When compared with the type 1 ICU group, the adjusted HRs for in-hospital mortality were 1.12 (95% CI 1.04 to 1.21) for the type 2 ICU group and 1.17 (95% CI 1.08 to 1.26) for the HCU group.

CONCLUSION

ICUs that fulfil more stringent staffing criteria were associated with lower in-hospital mortality among patients with sepsis than HCUs. Differences in organisational structure may have an association with outcomes in patients with sepsis, and this was observed by the NDB.

In-Hospital Triage

The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.

ICU Staffing in the United States

BACKGROUND

The last national estimates of US ICU physician staffing are 25 years old and lack information about interprofessional teams.

RESEARCH QUESTION

How are US adult ICUs currently staffed?

STUDY DESIGN AND METHODS

We conducted a cross-sectional survey (May 4, 2022-February 2, 2023) of adult ICU clinicians (targeting nurse/physician leadership) contacted using 2020 American Hospital Association (AHA) database information and, secondarily, through professional organizations. The survey included questions about interprofessional ICU staffing availability and roles at steady state (pre-COVID-19). We linked survey data to hospital data in the AHA database to create weighted national estimates by extrapolating ICU staffing data to nonrespondent hospitals based on hospital characteristics.

RESULTS

The cohort consisted of 596 adult ICUs (response rates: AHA contacts: 2.1%; professional organizations: unknown) with geographic diversity and size variability (median, 20 beds; interquartile range, 12-25); most cared for mixed populations (414 [69.5%]), yet medical (55 [9.2%]), surgical (70 [11.7%]), and specialty (57 [9.6%]) ICUs were well represented. A total of 554 (93.0%) had intensivists available, with intensivists covering all patients in 75.6% of these and onsite 24 h/d in one-half (53.3% weekdays; 51.8% weekends). Of all ICUs, 69.8% had physicians-in-training and 77.7% had nurse practitioners/physician assistants. For patients on mechanical ventilation, nurse to patient ratios were 1:2 in 89.6% of ICUs. Clinical pharmacists were available in 92.6%, and respiratory therapists were available in 98.8%. We estimated 85.1% (95% CI, 85.7%-84.5%) of hospitals nationally had ICUs with intensivists, 51.6% (95% CI, 50.6%-52.5%) had physicians-in-training, 72.1% (95% CI, 71.3%-72.9%) had nurse practitioners/physician assistants, 98.5% (95% CI, 98.4%-98.7%) had respiratory therapists, and 86.9% (95% CI, 86.4%-87.4%) had clinical pharmacists. For patients on mechanical ventilation, 86.4% (95% CI, 85.8%-87.0%) used 1:2 nurses/patients.

INTERPRETATION

We found that intensivist presence in adult US ICUs has greatly increased over 25 years. Intensivists, respiratory therapists, and clinical pharmacists are commonly available, and each nurse usually provides care for two patients on mechanical ventilation. However, team composition and workload vary.

Association Between In-hospital Mortality and the Institutional Factors of Intensive Care Units with a Focus on the Intensivist- to-bed Ratio: A Retrospective Cohort Study

Purpose: To elucidate the relationship between in-hospital mortality and the institutional factors of intensive care units (ICUs), with a focus on the intensivist-to-bed ratio. Methods: A retrospective cohort study was conducted using a Japanese ICU database, including adult patients admitted between April 1, 2020 and March 31, 2021. We used a multilevel logistic regression model to investigate the associations between in-hospital mortality and the following institutional factors: the intensivist-to-bed ratios on weekdays or over weekends/holidays, different work shifts, hospital-to-ICU-bed ratio, annual-ICU-admission-to-bed ratio, type of hospital, and the presence of other medical staff. Results: The study population comprised 46 503 patients admitted to 65 ICUs. The in-hospital mortality rate was 8.1%. The median numbers of ICU beds and intensivists were 12 (interquartile range [IQR] 8-14) and 4 (IQR 2-9), respectively. In-hospital mortality decreased significantly as the intensivist-to-bed ratio at 10 am on weekdays increased: the average contrast indicated a 20% (95% confidence interval [CI]: 1%-38%) reduction when the ratio increased from 0 to 0.5, and a 38% (95% CI: 9%-67%) reduction when the ratio increased from 0 to 1. The other institutional factors did not present a significant effect. Conclusions: The intensivist-to-bed ratio at 10 am on weekdays had a significant effect on in-hospital mortality. Further investigation is needed to understand the processes leading to improved outcomes.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study

OBJECTIVES

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Clinician views on actionable processes of care for prolonged stay intensive care patients and families: A descriptive qualitative study

OBJECTIVES

To explore clinician perspectives on key actionable processes of care that may improve outcomes and experience of patients experiencing a prolonged (over 7 days) intensive care unit stay, and their family members.

RESEARCH METHODOLOGY

A descriptive qualitative interview study in the United Kingdom. We conducted online semi-structured interviews using video conferencing software (October 2020-August 2022). We used purposive sampling ensuring participation from a broad range of professions representing the interprofessional team in the United Kingdom. We used Framework Analysis methods to group actionable processes into the six themes of person-centred care. Analyses were informed by our previous scoping review and previous interviews with former patients and family members.

FINDINGS

We interviewed 24 staff participants and identified 36 actionable processes of care under six themes of person-centred care. Processes relating to communication (both establishing an effective communication method for the patient and staff communication with the patient and family), continuity of staff and care plans, and personalising the environment and routines, and allowing flexible family visiting were most frequently articulated. These processes were perceived as having a multifaceted impact on patient and family wellbeing, for example family visiting helping patient and family emotional wellbeing and staff communication with family; and establishing an effective communication method for patients reduced their anxiety, enhanced their involvement in their care and allowed staff to include them in ward rounds more efficiently.

CONCLUSION

We identified 36 actionable processes of care from interviews with intensive care staff, with an emphasis on enhancing patient autonomy through optimising communication and involvement in decision-making, participation of family, and continuity of staff and care plans.

IMPLICATIONS FOR CLINICAL PRACTICE

These 36 actionable processes of care will contribute to future development of quality improvement tools, which will be used to standardise the care of prolonged-stay intensive care patients and their families.

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

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.

The Critical Care Resource Intensivist Model: An Essential Component to Critical Care Nursing

At a large academic level 1 trauma center, an additional resource was added at night, the Critical Care Resource Intensivist (CCRI), which is a multi-disciplinary group of fellowship trained intensivists. Prior to implementation of this additional resource, concurrent to implementation and one-year post implementation, critical care (CC) nurses that provide care in the surgical, neurologic, medical, and cardiac intensive care units (ICU) were anonymously surveyed to evaluate the CCRI model from a nursing perspective. Survey results were aggregated via an electronic cloud-based survey tool. Our goal was to obtain qualitative data to inform hypothesis generation and quality improvement questions. As such, we collected free-text answers to the questions, "Do you ever have concerns about availability of faculty in the ICU?" and, "Do you have any suggestions or comments after implementation of CCRI?" Answers were categorized into pre- and postCCRI strata. When coding the data, the investigators found a total of 9 themes that connected all the free-text survey. The themes included faculty accessibility, nurse safety, satisfaction, continuum of care and patient safety, to name a few. CCRI was uniformly and unanimously felt to improve patient care and decrease provider stress, because of improved availability and responsiveness of cc-faculty. The need to expand the CCRI model across institutional campuses was also stated clearly within their responses. These surveys demonstrate the strong support for the CCRI model by CC nurse providers. Further studies should investigate the effects of CCRI on nurse provider burnout and turnover, especially given recent crises in nursing.

Implementing strategies to prevent infections in acute-care settings

This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.

Implementation of a Virtual Interprofessional ICU Learning Collaborative: Successes, Challenges, and Initial Reactions From the Structured Team-Based Optimal Patient-Centered Care for Virus COVID-19 Collaborators

Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes.

OBJECTIVES

The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 ICU Collaborative was created to identify and speed implementation of best evidence based COVID-19 practices.

DESIGN SETTING AND PARTICIPANTS

This 6-month project included volunteer interprofessional teams from VIRUS Registry sites, who received online training on the Checklist for Early Recognition and Treatment of Acute Illness and iNjury approach, a structured and systematic method for delivering evidence based critical care. Collaborators participated in weekly 1-hour videoconference sessions on high impact topics, monthly quality improvement (QI) coaching sessions, and received extensive additional resources for asynchronous learning.

MAIN OUTCOMES AND MEASURES

Outcomes included learner engagement, satisfaction, and number of QI projects initiated by participating teams.

RESULTS

Eleven of 13 initial sites participated in the Collaborative from March 2, 2021, to September 29, 2021. A total of 67 learners participated in the Collaborative, including 23 nurses, 22 physicians, 10 pharmacists, nine respiratory therapists, and three nonclinicians. Site attendance among the 11 sites in the 25 videoconference sessions ranged between 82% and 100%, with three sites providing at least one team member for 100% of sessions. The majority reported that topics matched their scope of practice (69%) and would highly recommend the program to colleagues (77%). A total of nine QI projects were initiated across three clinical domains and focused on improving adherence to established critical care practice bundles, reducing nosocomial complications, and strengthening patient- and family-centered care in the ICU. Major factors impacting successful Collaborative engagement included an engaged interprofessional team; an established culture of engagement; opportunities to benchmark performance and accelerate institutional innovation, networking, and acclaim; and ready access to data that could be leveraged for QI purposes.

CONCLUSIONS AND RELEVANCE

Use of a virtual platform to establish a learning collaborative to accelerate the identification, dissemination, and implementation of critical care best practices for COVID-19 is feasible. Our experience offers important lessons for future collaborative efforts focused on improving ICU processes of care.

Intensivist physician-to-patient ratios and mortality in the intensive care unit

PURPOSE

A high daily census may hinder the ability of physicians to deliver quality care in the intensive care unit (ICU). We sought to determine the relationship between intensivist-to-patient ratios and mortality among ICU patients.

METHODS

We performed a retrospective cohort study of intensivist-to-patient ratios in 29 ICUs in 10 hospitals in the United States from 2018 to 2020. We used meta-data from progress notes in the electronic health record to determine an intensivist-specific caseload for each ICU day. We then fit a multivariable proportional hazards model with time-varying covariates to estimate the relationship between the daily intensivist-to-patient ratio and ICU mortality at 28 days.

RESULTS

The final analysis included 51,656 patients, 210,698 patient days, and 248 intensivist physicians. The average caseload per day was 11.8 (standard deviation: 5.7). There was no association between the intensivist-to-patient ratio and mortality (hazard ratio for each additional patient: 0.987, 95% confidence interval: 0.968-1.007, p = 0.2). This relationship persisted when we defined the ratio as caseload over the sample-wide average (hazard ratio: 0.907, 95% confidence interval: 0.763-1.077, p = 0.26) and cumulative days with a caseload over the sample-wide average (hazard ratio: 0.991, 95% confidence interval: 0.966-1.018, p = 0.52). The relationship was not modified by the presence of physicians-in-training, nurse practitioners, and physician assistants (p value for interaction term: 0.14).

CONCLUSIONS

Mortality for ICU patients appears resistant to high intensivist caseloads. These results may not generalize to ICUs organized differently than those in this sample, such as ICUs outside the United States.

Development and pilot testing of PROACTIVE: A pediatric onco-critical care capacity and quality assessment tool for resource-limited settings

BACKGROUND

Nearly 90% children with cancer reside in low- and middle-income countries, which face multiple challenges delivering high-quality pediatric onco-critical care (POCC). We recently identified POCC quality and capacity indicators for PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), a tool that evaluates strengths and limitations in POCC services. This study describes pilot testing of PROACTIVE, development of center-specific reports, and identification of common POCC challenges.

METHODS

The original 119 consensus-derived PROACTIVE indicators were converted into 182 questions divided between 2 electronic surveys for intensivists and oncologists managing critically ill pediatric cancer patients. Alpha-testing was conducted to confirm face-validity with four pediatric intensivists. Eleven centers representing diverse geographic regions, income levels, and POCC services conducted beta-testing to evaluate usability, feasibility, and applicability of PROACTIVE. Centers' responses were scored and indicators with mean scores ≤75% in availability/performance were classified as common POCC challenges.

RESULTS

Alpha-testing ensured face-validity and beta-testing demonstrated feasibility and usability of PROACTIVE (October 2020-June 2021). Twenty-two surveys (response rate 99.4%) were used to develop center-specific reports. Adjustments to PROACTIVE were made based on focus group feedback and surveys, resulting in 200 questions. Aggregated data across centers identified common POCC challenges: (1) lack of pediatric intensivists, (2) absence of abstinence and withdrawal symptoms monitoring, (3) shortage of supportive care resources, and (4) limited POCC training for physicians and nurses.

CONCLUSIONS

PROACTIVE is a feasible and contextually appropriate tool to help clinicians and organizations identify challenges in POCC services across a wide range of resource-levels. Widespread use of PROACTIVE can help prioritize and develop tailored interventions to strengthen POCC services and outcomes globally.

Patient and hospital characteristics predict prolonged emergency department length of stay and in-hospital mortality: a nationwide analysis in Korea

BACKGROUND

Prolonged emergency department length of stay (EDLOS) in critically ill patients leads to increased mortality. This nationwide study investigated patient and hospital characteristics associated with prolonged EDLOS and in-hospital mortality in adult patients admitted from the emergency department (ED) to the intensive care unit (ICU).

METHODS

We conducted a retrospective cohort study using data from the National Emergency Department Information System. Prolonged EDLOS was defined as an EDLOS of ≥ 6 h. We constructed multivariate logistic regression models of patient and hospital variables as predictors of prolonged EDLOS and in-hospital mortality.

RESULTS

Between 2016 and 2019, 657,622 adult patients were admitted to the ICU from the ED, representing 2.4% of all ED presentations. The median EDLOS of the overall study population was 3.3 h (interquartile range, 1.9-6.1 h) and 25.3% of patients had a prolonged EDLOS. Patient characteristics associated with prolonged EDLOS included night-time ED presentation and Charlson comorbidity index (CCI) score of 1 or higher. Hospital characteristics associated with prolonged EDLOS included a greater number of staffed beds and a higher ED level. Prolonged EDLOS was associated with in-hospital mortality after adjustment for selected confounders (adjusted odds ratio: 1.18, 95% confidence interval: 1.16-1.20). Patient characteristics associated with in-hospital mortality included age ≥ 65 years, transferred-in, artificially ventilated in the ED, assignment of initial triage to more urgency, and CCI score of 1 or higher. Hospital characteristics associated with in-hospital mortality included a lesser number of staffed beds and a lower ED level.

CONCLUSIONS

In this nationwide study, 25.3% of adult patients admitted to the ICU from the ED had a prolonged EDLOS, which in turn was significantly associated with an increased in-hospital mortality risk. Hospital characteristics, including the number of staffed beds and the ED level, were associated with prolonged EDLOS and in-hospital mortality.

The Use of Electronic Health Record Metadata to Identify Nurse-Patient Assignments in the Intensive Care Unit: Algorithm Development and Validation

Background

Nursing care is a critical determinant of patient outcomes in the intensive care unit (ICU). Most studies of nursing care have focused on nursing characteristics aggregated across the ICU (eg, unit-wide nurse-to-patient ratios, education, and working environment). In contrast, relatively little work has focused on the influence of individual nurses and their characteristics on patient outcomes. Such research could provide granular information needed to create evidence-based nurse assignments, where a nurse’s unique skills are matched to each patient’s needs. To date, research in this area is hindered by an inability to link individual nurses to specific patients retrospectively and at scale.

Objective

This study aimed to determine the feasibility of using nurse metadata from the electronic health record (EHR) to retrospectively determine nurse-patient assignments in the ICU.

Methods

We used EHR data from 38 ICUs in 18 hospitals from 2018 to 2020. We abstracted data on the time and frequency of nurse charting of clinical assessments and medication administration; we then used those data to iteratively develop a deterministic algorithm to identify a single ICU nurse for each patient shift. We examined the accuracy and precision of the algorithm by performing manual chart review on a randomly selected subset of patient shifts.

Results

The analytic data set contained 5,479,034 unique nurse-patient charting times; 748,771 patient shifts; 87,466 hospitalizations; 70,002 patients; and 8,134 individual nurses. The final algorithm identified a single nurse for 97.3% (728,533/748,771) of patient shifts. In the remaining 2.7% (20,238/748,771) of patient shifts, the algorithm either identified multiple nurses (4,755/748,771, 0.6%), no nurse (14,689/748,771, 2%), or the same nurse as the prior shift (794/748,771, 0.1%). In 200 patient shifts selected for chart review, the algorithm had a 93% accuracy (ie, correctly identifying the primary nurse or correctly identifying that there was no primary nurse) and a 94.4% precision (ie, correctly identifying the primary nurse when a primary nurse was identified). Misclassification was most frequently due to patient transitions in care location, such as ICU transfers, discharges, and admissions.

Conclusions

Metadata from the EHR can accurately identify individual nurse-patient assignments in the ICU. This information enables novel studies of ICU nurse staffing at the individual nurse-patient level, which may provide further insights into how nurse staffing can be leveraged to improve patient outcomes.

Hospital characteristics associated with COVID-19 mortality: data from the multicenter cohort Brazilian Registry

The COVID-19 pandemic caused unprecedented pressure over health care systems worldwide. Hospital-level data that may influence the prognosis in COVID-19 patients still needs to be better investigated. Therefore, this study analyzed regional socioeconomic, hospital, and intensive care units (ICU) characteristics associated with in-hospital mortality in COVID-19 patients admitted to Brazilian institutions. This multicenter retrospective cohort study is part of the Brazilian COVID-19 Registry. We enrolled patients ≥ 18 years old with laboratory-confirmed COVID-19 admitted to the participating hospitals from March to September 2020. Patients' data were obtained through hospital records. Hospitals' data were collected through forms filled in loco and through open national databases. Generalized linear mixed models with logit link function were used for pooling mortality and to assess the association between hospital characteristics and mortality estimates. We built two models, one tested general hospital characteristics while the other tested ICU characteristics. All analyses were adjusted for the proportion of high-risk patients at admission. Thirty-one hospitals were included. The mean number of beds was 320.4 ± 186.6. These hospitals had eligible 6556 COVID-19 admissions during the study period. Estimated in-hospital mortality ranged from 9.0 to 48.0%. The first model included all 31 hospitals and showed that a private source of funding (β = - 0.37; 95% CI - 0.71 to - 0.04; p = 0.029) and location in areas with a high gross domestic product (GDP) per capita (β = - 0.40; 95% CI - 0.72 to - 0.08; p = 0.014) were independently associated with a lower mortality. The second model included 23 hospitals and showed that hospitals with an ICU work shift composed of more than 50% of intensivists (β = - 0.59; 95% CI - 0.98 to - 0.20; p = 0.003) had lower mortality while hospitals with a higher proportion of less experienced medical professionals had higher mortality (β = 0.40; 95% CI 0.11-0.68; p = 0.006). The impact of those association increased according to the proportion of high-risk patients at admission. In-hospital mortality varied significantly among Brazilian hospitals. Private-funded hospitals and those located in municipalities with a high GDP had a lower mortality. When analyzing ICU-specific characteristics, hospitals with more experienced ICU teams had a reduced mortality.

Root Cause Analysis (RCA) of Adverse Events in One of the Biggest Western Iranian General Hospitals: Short Communication

Background: In developing and underdeveloped countries, medical error is often either not reported or reported improperly for various reasons. Root cause analysis (RCA) is a systematic method to determine how various factors contribute to the occurrence of medical errors. Objectives: The current study analyzed the root cause of one of western Iran’s biggest general hospitals. Methods: This retrospective RCA was conducted through a qualitative approach in 2019 following the National Patient Safety Agency (NPSA) protocol in seven steps: Initialization of the process, collecting and mapping information, identifying issues related to care delivery problems (CDP) or service delivery problems (SDP), event analysis, identifying the involved factors in the event - root causes, providing solutions, implementing solutions, and submission of reports. Results: According to the results of this study, 61 cases were examined, and committees accepted the errors in 11 cases. Here, 49 CDP and 13 SDP factors were identified. Care delivery problems factors were selected for all events based on the team’s viewpoints. Overall, task-related causes (20 cases), individual causes (17 cases), management-related causes (14 cases), training-related causes (8 cases), and causes related to work environment and conditions (7 cases) were specified. Conclusions: Accepting mistakes is the first step in the hope of improvement. In this hospital, only 11 cases of mistakes had been accepted by the authorities. In most cases, the proposed solutions to this issue included personnel training, monitoring system strengthening, and developing and standardizing processes. Overall, this study and other similar studies showed errors during service delivery and through service providers.

Quality Improvement in Neurocritical Care: a Review of the Current Landscape and Best Practices

Purpose of Review

The field of neurocritical care (NCC) has grown such that there is now a substantial body of literature on quality improvement specific to NCC. This review will discuss the development of this literature over time and highlight current best practices with practical tips for providers.

Recent Findings

There is tremendous variability in patient care models for NCC patients, despite evidence showing that certain structural elements are associated with better outcomes. There now also exist evidence-based recommendations for neurocritical care unit (NCCU) structure and processes, as well as NCC-specific performance measure (PM) sets; however, awareness of these is variable among care providers. The evidence-based literature on NCC structure, staffing, training, standardized order sets and bundles, transitions of care including handoff, prevention of bounce backs, bed flow optimization, and inter-hospital transfers is growing and offers many examples of successful performance improvement initiatives in NCCUs.

Summary

NCC providers care for patients with life-threatening conditions like intracerebral and subarachnoid hemorrhages, ischemic stroke, and traumatic brain injury, which are associated with high morbidity, complexity of treatment, and cost. Quality improvement initiatives have been successful in improving many aspects of NCC patient care, and NCC providers should continue to update and standardize their practices with consideration of this data. More research is needed to continue to identify high-risk and high-cost NCCU structures and processes and strategies to optimize them, validate current NCC PMs, and encourage clinical adoption of those that prove to be associated with improved outcomes.

The Post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part II: Clinical engagement and future directions for the national Post-Intensive care Rehabilitation Collaborative

BACKGROUND

Many Intensive Care Unit (ICU) survivors suffer from a multi- system disability, termed the post-intensive care syndrome. There is no current national coordination of either rehabilitation pathways or related data collection for them. In the last year, the need for tools to systematically identify the multidisciplinary rehabilitation needs of severely affected COVID-19 survivors has become clear. Such tools offer the opportunity to improve rehabilitation for all critical illness survivors through provision of a personalised Rehabilitation Prescription (RP). The initial development and secondary refinement of such an assessment and data tools is described in the linked paper. We report here the clinical and workforce data that was generated as a result.

METHODS

Prospective service evaluation of 26 acute hospitals in England using the Post-ICU Presentation Screen (PICUPS) tool and the RP. The PICUPS tool comprised items in domains of a) Medical and essential care, b) Breathing and nutrition; c) Physical movement and d) Communication, cognition and behaviour.

RESULTS

No difference was seen in total PICUPS scores between patients with or without COVID-19 (77 (IQR 60-92) vs. 84 (IQR 68-97); Mann-Whitney z = -1.46, p = 0.144. A network analysis demonstrated that requirements for physiotherapy, occupational therapy, speech and language therapy, dietetics and clinical psychology were closely related and unaffected by COVID-19 infection status. A greater proportion of COVID-19 patients were referred for inpatient rehabilitation (13% vs. 7%) and community-based rehabilitation (36% vs.15%). The RP informed by the PICUPS tool generally specified a greater need for multi-professional input when compared to rehabilitation plans instituted.

CONCLUSIONS

The PICUPS tool is feasible to implement as a screening mechanism for post-intensive care syndrome. No differences are seen in the rehabilitation needs of patients with and without COVID-19 infection. The RP could be the vehicle that drives the professional interventions across the transitions from acute to community care. No single discipline dominates the rehabilitation requirements of these patients, reinforcing the need for a personalised RP for critical illness survivors.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Current stage of the intensive care unit structure in Argentina: results from the Sociedad Argentina de Terapia Intensiva self-assessment survey of intensive care units

OBJECTIVE

To describe and compare the structure of Argentinean intensive care units that completed the "self-assessment survey of intensive care units" developed by the Sociedad Argentina de Terapia Intensiva.

METHODS

An observational crosssectional study was conducted using an online voluntary survey through the Sociedad Argentina de Terapia Intensiva member database and other social media postings. Answers received between December 2018 and July 2020 were analyzed. Descriptive statistics and nonparametric tests were used.

RESULTS

A total of 392 surveys were received, and 244 were considered for the analysis. Seventy-seven percent (187/244) belonged to adult intensive care units, and 23% (57/244) belonged to pediatric intensive care units. The overall completion rate was 76%. The sample included 2,567 ICU beds (adult: 1,981; pediatric: 586). We observed a clear concentration of intensive care units in the Central and Buenos Aires regions of Argentina. The median number of beds was 10 (interquartile range 7 - 15).The median numbers of multiparameter monitors, mechanical ventilators, and pulse oximeters were 1 per bed with no regional or intensive care unit type differences (adult versus pediatric). Although our sample showed that the pediatric intensive care units had a higher mechanical ventilation/bed ratio than the adult intensive care units, this finding was not linearly correlated.

CONCLUSION

Argentina has a notable concentration of critical care beds and better structural complexity in the Buenos Aires and Centro regions for both adult and pediatric intensive care units. In addition, a lack of accurate data reported from the intensive care unit structure and resources was observed. Further improvement opportunities are required to allocate intensive care unit resources at the institutional and regional levels.

Clinical Nurse Specialist: A Critical Member of the ICU Team

OBJECTIVES

To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided.

DATA SOURCES

Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical-Care Nurses, and National Association of Clinical Nurse Specialists.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Not applicable.

DATA SYNTHESIS

Not applicable.

CONCLUSIONS

The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

White Paper on Early Critical Care Services in Low Resource Settings

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS.

LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities.

Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient—these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel.

Currently, a single “best” care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy.

Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country’s current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum.

Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement.

Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient’s geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

A Comfort Measures Only Checklist for Critical Care Providers: Impact on Satisfaction and Symptom Management

PURPOSE

This quality improvement project created a guide for critical care providers transitioning patients to comfort measures only encouraging communication, collaboration, and shared decision making; ensuring management of patients' end-of-life symptoms and needs; and enhancing provider satisfaction by improving structure and consistency when transitioning patients.

DESCRIPTION OF THE PROJECT

Interviews conducted with staff in intensive care units revealed opportunities to improve structure and processes of transitioning patients at the end of life. A subcommittee of experts designed a checklist to facilitate interdisciplinary conversations. Impact on provider satisfaction and symptom management was assessed. Presurveys circulated used a Research Electronic Data Capture tool. A checklist was implemented for 3 months, and then postsurveys were sent. Charts were audited to identify improvement in symptom management and compared with retrospective samples.

OUTCOMES

Clinical improvements were seen in communication (12%), collaboration (25%), shared decision making (22%), and order entry time (17%). In addition, 72% agreed the checklist improved structure and consistency; 69% reported improved communication, collaboration, and shared decision making; 61% felt it improved knowledge/understanding of patient needs; and 69% agreed it improved management of patient symptoms.

CONCLUSION

After checklist implementation, staff felt more involved and more comfortable, and reported more clarity in transitioning patients; no improvement in patient outcomes was realized.

Clinical Nurse Specialist: A Critical Member of the ICU Team

OBJECTIVES

To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided.

DATA SOURCES

Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical Care Nurses, and National Association of Clinical Nurse Specialists.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Not applicable.

DATA SYNTHESIS

Not applicable.

CONCLUSIONS

The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Psychological Safety in Intensive Care Unit Rounding Teams

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.

Implications of State Scope-of-Practice Regulations for Pediatric Intensive Care Unit Nurse Practitioner Roles

Nurse practitioner (NP) advocacy efforts often focus on attaining full practice authority. While the effects of full practice authority in primary care are well described, implications for hospital-based NPs are less clear and may differ because of hospitals' team-based care and administrative structure. This study examines associations between state scope-of-practice (SSOP) and clinical roles of hospital-based pediatric intensive care unit (PICU) NPs. We conducted a national survey to assess clinical roles of PICU NPs including daily patient care, procedural, and consultation responsibilities as well as hospital-level administrative oversight practices. We classified SSOP as full or limited (reduced or restricted SSOP) practice. We present descriptive statistics and evaluate differences in clinical roles and hospital-level administrative oversight based on SSOP. The final sample included 55 medical directors and 58 lead (senior or supervisory) NPs from 93 of the 140 (66.4%) PICUs with NPs. There were no significant differences in daily patient care, procedural, or consultation responsibilities based on SSOP (p > .05). However, NPs in full practice authority states were more likely to bill for care than those in limited practice states (66.7% vs. 31.8%, p = .003), while those in limited practice states were more likely to report to advanced practice managers (36.7% vs. 13%, p = .03). For PICU NPs, SSOP was not associated with variation in clinical responsibilities; conversely, there were differences in billing and reporting practices. Future work is needed to understand implications of variation in hospital-level administrative oversight.

Advanced Practice Provider-inclusive Staffing Models and Patient Outcomes in Pediatric Critical Care

BACKGROUND

Pediatric intensive care units (PICUs) are increasingly staffed with advanced practice providers (APPs), supplementing traditional physician staffing models.

OBJECTIVES

We evaluate the effect of APP-inclusive staffing models on clinical outcomes and resource utilization in US PICUs.

RESEARCH DESIGN

Retrospective cohort study of children admitted to PICUs in 9 states in 2016 using the Healthcare Cost and Utilization Project's State Inpatient Databases. PICU staffing models were assessed using a contemporaneous staffing survey. We used multivariate regression to examine associations between staffing models with and without APPs and outcomes.

MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included odds of hospital acquired conditions and ICU and hospital lengths of stay.

RESULTS

The sample included 38,788 children in 40 PICUs. Patients admitted to PICUs with APP-inclusive staffing were younger (6.1±5.9 vs. 7.1±6.2 y) and more likely to have complex chronic conditions (64% vs. 43%) and organ failure on admission (25% vs. 22%), compared with patients in PICUs with physician-only staffing. There was no difference in mortality between PICU types [adjusted odds ratio (AOR): 1.23, 95% confidence interval (CI): 0.83-1.81, P=0.30]. Patients in PICUs with APP-inclusive staffing had lower odds of central line-associated blood stream infections (AOR: 0.76, 95% CI: 0.59-0.98, P=0.03) and catheter-associated urinary tract infections (AOR: 0.73, 95% CI: 0.61-0.86, P<0.001). There were no differences in lengths of stay.

CONCLUSIONS

Despite being younger and sicker, children admitted to PICUs with APP-inclusive staffing had no increased odds of mortality and lower odds of some hospital acquired conditions compared with those in PICUs with physician-only staffing. Further research can inform APP integration strategies which optimize outcomes.

Clinical Nurse Specialist: A Critical Member of the ICU Team

OBJECTIVES

To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided.

DATA SOURCES

Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical Care Nurses, and National Association of Clinical Nurse Specialists.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Not applicable.

DATA SYNTHESIS

Not applicable.

CONCLUSIONS

The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Using a Modified Surprise Question as a Tool to Improve Primary Palliative Care in a Neurocritical Care Unit

BACKGROUND

Specialty palliative care is a limited resource. The surprise question ("Would you be surprised if this patient died within the next 12 months?") is a screening tool for clinicians to identify people nearing the end of life. The researchers used a modified surprise question (MSQ) to improve primary palliative care in a neurocritical care unit.

METHODS

A palliative care physician attended interdisciplinary rounds up to three days a week and asked the primary neurocritical care team, for each patient admitted in the previous 24 hours, the MSQ: "Would you be surprised if this patient died during this hospital stay?" If the response was "No," the unit social worker identified the patient's surrogate decision maker (SDM), and the primary team was encouraged to conduct a goals of care (GOC) conversation. The frequency of SDM documentation, occurrence and timing of GOC conversations, and palliative care and hospice consultations were measured for the baseline six months before the intervention, and six months after.

RESULTS

Among 350 patients admitted to the neurocritical care unit during the study, the age, gender, prehospitalization presence of advance directives, and mortality were comparable between the baseline (n = 173) and intervention (n = 177) periods. Compared to the baseline period, there was a higher frequency during the intervention period of documentation of SDM (31.8% vs. 54.2%, p = 0.00002), all GOC conversations (35.3% vs. 53.1%, p = 0.008), GOC conversations conducted by the primary team (27.2% vs. 47.5%, p = 0.00009), palliative care consultations (11.6% vs. 23.2%, p = 0.004), and hospice consultations (2.3% vs. 9.6%, p = 0.004).

CONCLUSION

The MSQ can be used as a tool to identify the risk of mortality, facilitate palliative care delivered by the primary team, and improve end-of-life care.

Number of intensivists per bed is associated with efficiency of Dutch intensive care units

PURPOSE

To measure efficiency in Intensive Care Units (ICUs) and to determine which organizational factors are associated with ICU efficiency, taking confounding factors into account.

MATERIALS AND METHODS

We used data of all consecutive admissions to Dutch ICUs between January 1, 2016 and January 1, 2019 and recorded ICU organizational factors. We calculated efficiency for each ICU by averaging the Standardized Mortality Ratio (SMR) and Standardized Resource Use (SRU) and examined the relationship between various organizational factors and ICU efficiency. We thereby compared the results of linear regression models before and after covariate adjustment using propensity scores.

RESULTS

We included 164,399 admissions from 83 ICUs. ICU efficiency ranged from 0.51-1.42 (average 0.99, 0.15 SD). The unadjusted model as well as the propensity score adjusted model showed a significant association between the ratio of employed intensivists per ICU bed and ICU efficiency. Other organizational factors had no statistically significant association with ICU efficiency after adjustment.

CONCLUSIONS

We found marked variability in efficiency in Dutch ICUs. After applying covariate adjustment using propensity scores, we identified one organizational factor, ratio intensivists per bed, having an association with ICU efficiency.

Implementing the ABCDE Bundle, Critical-Care Pain Observation Tool, and Richmond Agitation-Sedation Scale to Reduce Ventilation Time

Prolonged mechanical ventilation of patients in intensive care units across the United States consumes billions of health care dollars every year. Using the awakening and breathing coordination, delirium monitoring/management, and early mobility (ABCDE) bundle along with the Critical-Care Pain Observation Tool and the Richmond Agitation-Sedation Scale combines the best available evidence to optimize outcomes for critically ill patients. This study is the first to examine the effects of implementing the ABCDE bundle, the Critical-Care Pain Observation Tool, and the Richmond Agitation-Sedation Scale together in a coordinated effort across multiple disciplines. The aim of using this combination of evidence-based tools is to reduce ventilation time by reducing oversedation, decreasing the incidence of delirium, and improving pain management.

Organizational Characteristics Associated With ICU Liberation (ABCDEF) Bundle Implementation by Adult ICUs in Michigan

The ICU Liberation (ABCDEF) Bundle can help to improve care and outcomes for ICU patients, but bundle implementation is far from universal. Understanding how ICU organizational characteristics influence bundle implementation could inform quality improvement efforts. We surveyed all hospitals in Michigan with adult ICUs to determine whether organizational characteristics were associated with bundle implementation and to determine the level of agreement between ICU physician and nurse leaders around ICU organizational characteristics and bundle implementation.

Design

We surveyed ICU physician and nurse leaders, assessing their safety culture, ICU team collaboration, and work environment. Using logistic and linear regression models, we compared these organizational characteristics to bundle element implementation, and also compared physician and nurse leaders' perceptions about organizational characteristics and bundle implementation.

Setting

All (n = 72) acute care hospitals with adult ICUs in Michigan.

Subjects

ICU physician and nurse leader pairs from each hospital's main ICU.

Interventions

We developed, pilot-tested, and deployed an electronic survey to all subjects over a 3 month period in 2016.

Results

Results from 73 surveys (28 physicians, 45 nurses, 60% hospital response rate) demonstrated significant variation in hospital and ICU size and type, organizational characteristics, and physician/nurse perceptions of ICU organization and bundle implementation. We found that a robust safety culture and collaborative work environment that uses checklists to facilitate team communication are strongly associated with bundle implementation. There is also a significant dose-response effect between safety culture, a collaborative work environment, and overall bundle implementation.

Conclusions

We identified several specific ICU practices that can facilitate ABCDEF Bundle implementation. Our results can be used to develop effective bundle implementation strategies that leverage safety culture, interprofessional collaboration, and routine checklist use in ICUs to improve bundle implementation and performance.

Implementation of an Academic-to-Community Hospital Intensive Care Unit Quality Improvement Program. Qualitative Analysis of Multilevel Facilitators and Barriers

Rationale: Implementation of evidence-based best practices is influenced by a variety of contextual factors. It is vital to characterize such factors to maintain high-quality care. Patients in the intensive care unit (ICU) are critically ill and require complex, interdisciplinary, evidence-based care to enable high-quality outcomes. Objectives: To identify facilitators and barriers to implementation of an academic-to-community hospital ICU interprofessional quality improvement program, "ICU Innovations." Methods: ICU Innovations is a multimodal quality improvement program implemented between 2014 and 2017 in six community ICUs in rural settings serving underserved patients in South Carolina. ICU Innovations includes quarterly on-site seminars and extensive behind the scenes facilitation to catalyze the implementation of evidence-based best practices. We use qualitative analysis to identify contextual factors related to program implementation processes. Guided by an implementation science framework, the Exploration, Adoption/Preparation, Implementation, Sustainment framework, we conducted semistructured key informant interviews with clinician champions at six community ICUs and six parallel interviews with ICU Innovations' leadership. We developed a qualitative coding template based on the framework and identified contextual factors associated with implementation. Standard data on hospital and ICU structure and processes of care were also collected. Results: Outer and inner factors interconnected dynamically to influence implementation of ICU Innovations. Collaborative engagement between the program developers and partner sites (outer context factor) and site program champion leadership and staff readiness for change (inner context factors) were key influences of implementation. Conclusions: This research focused on rural hospital ICUs with limited or nonexistent intensivist leadership. Although enthusiasm for the ICU Innovations program was initially high, implementation was challenging because of multiple contextual factors. Critical steps for implementation of evidence-based practice in rural hospitals include optimizing engagement with external collaborators, maximizing the role of a committed site champion, and conducting thorough site assessments to ensure staff and organizational readiness for change. Identifying barriers and facilitators to program implementation is an on-going process to tailor and improve program initiatives.

Cardiac intensive care in Portugal: The time for change

In recent years, the number of patients requiring acute cardiac care has increased, with progressively more complex cardiovascular conditions, often complicated by acute or chronic non-cardiovascular comorbidities, which affects the management and prognosis of these patients. Coronary care units have evolved into cardiac intensive care units, which provide highly specialized health care for the critical heart patient. In view of the limited human and technical resources in this area, we consider that there is an urgent need for an in-depth analysis of the organizational model for acute cardiac care, including the definition of the level of care, the composition and training of the team, and the creation of referral networks. It is also crucial to establish protocols and to adopt safe clinical practices to improve levels of quality and safety in the treatment of patients. Considering that acute cardiac care involves conditions with very different severity and prognosis, it is essential to define the level of care to be provided for each type of acute cardiovascular condition in terms of the team, available techniques and infrastructure. This will lead to improvements in the quality of care and patient prognosis, and will also enable more efficient allocation of resources.

Establishing the Knowledge and Skills Necessary in Pediatric Critical Care Medicine: A Systematic Approach to Practice Analysis

OBJECTIVES

To describe the practice analysis undertaken by a task force convened by the American Board of Pediatrics Pediatric Critical Care Medicine Sub-board to create a comprehensive document to guide learning and assessment within Pediatric Critical Care Medicine.

DESIGN

An in-depth practice analysis with a mixed-methods design involving a descriptive review of practice, a modified Delphi process, and a survey.

SETTING

Not applicable.

SUBJECTS

Seventy-five Pediatric Critical Care Medicine program directors and 2,535 American Board of Pediatrics Pediatric Critical Care Medicine diplomates.

INTERVENTIONS

A practice analysis document, which identifies the full breadth of knowledge and skill required for the practice of Pediatric Critical Care Medicine, was developed by a task force made up of seven pediatric intensivists and a psychometrician. The document was circulated to all 75 Pediatric Critical Care Medicine fellowship program directors for review and comment and their feedback informed modifications to the draft document. Concurrently, data from creation of the practice analysis draft document were also used to update the Pediatric Critical Care Medicine, was developed by a task force made up of seven pediatric intensivists and a psychometrician. The document was circulated to all 75 Pediatrics Pediatric Critical Care Medicine fellowship program directors for review and comment and their feedback informed modifications to the draft document. Concurrently, data from creation of the practice analysis draft document were also used to update the Pediatric Critical Care Medicine content outline, which was sent to all 2,535 American Board of Pediatrics Pediatric Critical Care Medicine diplomates for review during an open-comment period between January 2019 and February 2019, and diplomate feedback was used to make updates to both the content outline and the practice analysis document.

MEASUREMENTS AND MAIN RESULTS

After review and comment by 25 Pediatric Critical Care Medicine program directors (33.3%) and 619 board-certified diplomates (24.4%), a comprehensive practice analysis document was created through a two-stage process. The final practice analysis includes 10 performance domains which parallel previously published Entrustable Professional Activities in Pediatric Critical Care Medicine. These performance domains are made up of between three and eight specific tasks, with each task including the critical knowledge and skills that are necessary for successful completion. The final practice analysis document was also used by the American Board of Pediatrics Pediatric Critical Care Medicine Sub-board to update the Pediatric Critical Care Medicine content outline.

CONCLUSIONS

A systematic approach to practice analysis, with stakeholder engagement, is essential for an accurate definition of Pediatric Critical Care Medicine practice in its totality. This collaborative process resulted in a dynamic document useful in guiding curriculum development for training programs, maintenance of certification, and lifetime professional development to enable safe and efficient patient care.