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Krewulak KD, Knight G, Irwin A, Morrissey J, Stelfox HT, Bagshaw SM, Zuege D, Roze des Ordons A, Fiest K, Parhar KKS. Acceptability of the Venting Wisely pathway for use in critically ill adults with hypoxaemic respiratory failure and acute respiratory distress syndrome (ARDS): a qualitative study protocol. BMJ Open 2024; 14:e075086. [PMID: 38806421 PMCID: PMC11138268 DOI: 10.1136/bmjopen-2023-075086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/03/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Hypoxaemic respiratory failure (HRF) affects nearly 15% of critically ill adults admitted to an intensive care unit (ICU). An evidence-based, stakeholder-informed multidisciplinary care pathway (Venting Wisely) was created to standardise the diagnosis and management of patients with HRF and acute respiratory distress syndrome. Successful adherence to the pathway requires a coordinated team-based approach by the clinician team. The overall aim of this study is to describe the acceptability of the Venting Wisely pathway among critical care clinicians. Specifically, this will allow us to (1) better understand the user's experience with the intervention and (2) determine if the intervention was delivered as intended. METHODS AND ANALYSIS This qualitative study will conduct focus groups with nurse practitioners, physicians, registered nurses and registered respiratory therapists from 17 Alberta ICUs. We will use template analysis to describe the acceptability of a multicomponent care pathway according to seven constructs of acceptability: (1) affective attitude;,(2) burden, (3) ethicality, (4) intervention coherence, (5) opportunity costs, (6) perceived effectiveness and (7) self-efficacy. This study will contribute to a better understanding of the acceptability of the Venting Wisely pathway. Identification of areas of poor acceptability will be used to refine the pathway and implementation strategies as ways to improve adherence to the pathway and promote its sustainability. ETHICS AND DISSEMINATION The study was approved by the University of Calgary Conjoint Health Research Ethics Board. The results will be submitted for publication in a peer-reviewed journal and presented at a scientific conference. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT04744298.
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Affiliation(s)
- Karla D Krewulak
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gwen Knight
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Andrea Irwin
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jeanna Morrissey
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Henry Thomas Stelfox
- University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Sean M Bagshaw
- University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Danny Zuege
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | | - Kirsten Fiest
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Ken Kuljit Singh Parhar
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Nates JL, Oropello JM, Badjatia N, Beilman G, Coopersmith CM, Halpern NA, Herr DL, Jacobi J, Kahn R, Leung S, Puri N, Sen A, Pastores SM. Flow-Sizing Critical Care Resources. Crit Care Med 2023; 51:1552-1565. [PMID: 37486677 PMCID: PMC11192408 DOI: 10.1097/ccm.0000000000005967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVES To describe the factors affecting critical care capacity and how critical care organizations (CCOs) within academic centers in the U.S. flow-size critical care resources under normal operations, strain, and surge conditions. DATA SOURCES PubMed, federal agency and American Hospital Association reports, and previous CCO survey results were reviewed. STUDY SELECTION Studies and reports of critical care bed capacity and utilization within CCOs and in the United States were selected. DATA EXTRACTION The Academic Leaders in the Critical Care Medicine Task Force established regular conference calls to reach a consensus on the approach of CCOs to "flow-sizing" critical care services. DATA SYNTHESIS The approach of CCOs to "flow-sizing" critical care is outlined. The vertical (relation to institutional resources, e.g., space allocation, equipment, personnel redistribution) and horizontal (interdepartmental, e.g., emergency department, operating room, inpatient floors) integration of critical care delivery (ICUs, rapid response) for healthcare organizations and the methods by which CCOs flow-size critical care during normal operations, strain, and surge conditions are described. The advantages, barriers, and recommendations for the rapid and efficient scaling of critical care operations via a CCO structure are explained. Comprehensive guidance and resources for the development of "flow-sizing" capability by a CCO within a healthcare organization are provided. CONCLUSIONS We identified and summarized the fundamental principles affecting critical care capacity. The taskforce highlighted the advantages of the CCO governance model to achieve rapid and cost-effective "flow-sizing" of critical care services and provide recommendations and resources to facilitate this capability. The relevance of a comprehensive approach to "flow-sizing" has become particularly relevant in the wake of the latest COVID-19 pandemic. In light of the growing risks of another extreme epidemic, planning for adequate capacity to confront the next critical care crisis is urgent.
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Affiliation(s)
- Joseph L Nates
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | | | - Nitin Puri
- Cooper University Health Care, Camden, NJ
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Kohn R, Harhay MO, Weissman GE, Urbanowicz R, Wang W, Anesi GL, Scott S, Bayes B, Greysen SR, Halpern SD, Kerlin MP. A Data-Driven Analysis of Ward Capacity Strain Metrics That Predict Clinical Outcomes Among Survivors of Acute Respiratory Failure. J Med Syst 2023; 47:83. [PMID: 37542590 DOI: 10.1007/s10916-023-01978-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/18/2023] [Indexed: 08/07/2023]
Abstract
Supply-demand mismatch of ward resources ("ward capacity strain") alters care and outcomes. Narrow strain definitions and heterogeneous populations limit strain literature. Evaluate the predictive utility of a large set of candidate strain variables for in-hospital mortality and discharge destination among acute respiratory failure (ARF) survivors. In a retrospective cohort of ARF survivors transferred from intensive care units (ICUs) to wards in five hospitals from 4/2017-12/2019, we applied 11 machine learning (ML) models to identify ward strain measures during the first 24 hours after transfer most predictive of outcomes. Measures spanned patient volume (census, admissions, discharges), staff workload (medications administered, off-ward transports, transfusions, isolation precautions, patients per respiratory therapist and nurse), and average patient acuity (Laboratory Acute Physiology Score version 2, ICU transfers) domains. The cohort included 5,052 visits in 43 wards. Median age was 65 years (IQR 56-73); 2,865 (57%) were male; and 2,865 (57%) were white. 770 (15%) patients died in the hospital or had hospice discharges, and 2,628 (61%) were discharged home and 964 (23%) to skilled nursing facilities (SNFs). Ward admissions, isolation precautions, and hospital admissions most consistently predicted in-hospital mortality across ML models. Patients per nurse most consistently predicted discharge to home and SNF, and medications administered predicted SNF discharge. In this hypothesis-generating analysis of candidate ward strain variables' prediction of outcomes among ARF survivors, several variables emerged as consistently predictive of key outcomes across ML models. These findings suggest targets for future inferential studies to elucidate mechanisms of ward strain's adverse effects.
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Affiliation(s)
- Rachel Kohn
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Michael O Harhay
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gary E Weissman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Wei Wang
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - George L Anesi
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefania Scott
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - S Ryan Greysen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D Halpern
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Meeta Prasad Kerlin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Lavrentieva A, Kaimakamis E, Voutsas V, Bitzani M. An observational study on factors associated with ICU mortality in Covid-19 patients and critical review of the literature. Sci Rep 2023; 13:7804. [PMID: 37179397 PMCID: PMC10182846 DOI: 10.1038/s41598-023-34613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
The novel pandemic caused by SARS-CoV-2 has been associated with increased burden on healthcare system. Recognizing the variables that independently predict death in COVID-19 is of great importance. The study was carried out prospectively in a single ICU in northern Greece. It was based on the collection of data during clinical practice in 375 adult patients who were tested positive for SARS-CoV-2 between April 2020 and February 2022. All patients were intubated due to acute respiratory insufficiency and received Invasive Mechanical Ventilation. The primary outcome was ICU mortality. Secondary outcomes were 28-day mortality and independent predictors of mortality at 28 days and during ICU hospitalization. For continuous variables with normal distribution, t-test was used for means comparison between two groups and one-way ANOVA for multiple comparisons. When the distribution was not normal, comparisons were performed using the Mann-Whitney test. Comparisons between discrete variables were made using the x2 test, whereas the binary logistic regression was employed for the definition of factors affecting survival inside the ICU and after 28 days. Of the total number of patients intubated due to COVID-19 during the study period, 239 (63.7%) were male. Overall, the ICU survival was 49.6%, whereas the 28-day survival reached 46.9%. The survival rates inside the ICU for the four main viral variants were 54.9%, 50.3%, 39.7% and 50% for the Alpha, Beta, Delta and Omicron variants, respectively. Logistic regressions for outcome revealed that the following parameters were independently associated with ICU survival: wave, SOFA @day1, Remdesivir use, AKI, Sepsis, Enteral Insufficiency, Duration of ICU stay and WBC. Similarly, the parameters affecting the 28-days survival were: duration of stay in ICU, SOFA @day1, WBC, Wave, AKI and Enteral Insufficiency. In this observational cohort study of critically ill COVID-19 patients we report an association between mortality and the wave sequence, SOFA score on admission, the use of Remdesivir, presence of AKI, presence of gastrointestinal failure, sepsis and WBC levels. Strengths of this study are the large number of critically ill COVID-19 patients included, and the comparison of the adjusted mortality rates between pandemic waves within a two year-study period.
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Affiliation(s)
- Athina Lavrentieva
- 1st Intensive Care Unit, "G. Papanikolaou" General Hospital, 57010, Thessaloniki, Greece
| | - Evangelos Kaimakamis
- 1st Intensive Care Unit, "G. Papanikolaou" General Hospital, 57010, Thessaloniki, Greece.
| | - Vassileios Voutsas
- 1st Intensive Care Unit, "G. Papanikolaou" General Hospital, 57010, Thessaloniki, Greece
| | - Militsa Bitzani
- 1st Intensive Care Unit, "G. Papanikolaou" General Hospital, 57010, Thessaloniki, Greece
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An Exploration of Critical Care Professionals' Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study. Crit Care Explor 2023; 5:e0872. [PMID: 36890874 PMCID: PMC9988323 DOI: 10.1097/cce.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation. DESIGN Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used. SETTING Sixty-eight academic, community, and federal ICUs. PARTICIPANTS A total of 121 ICU professionals consisting of frontline and leadership professionals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient's) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol. CONCLUSIONS In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation.
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Rosen A, Carter D, Applebaum JR, Southern WN, Brodie D, Schwartz J, Cornelius T, Shelton RC, Yip NH, Pincus HA, Hwang C, Cooke J, Adelman JS. Critical Care Clinicians' Experiences of Patient Safety During the COVID-19 Pandemic. J Patient Saf 2022; 18:e1219-e1225. [PMID: 35948317 PMCID: PMC9696681 DOI: 10.1097/pts.0000000000001060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE It is unknown how hospital- and systems-level factors have impacted patient safety in the intensive care unit (ICU) during the COVID-19 pandemic. We sought to understand how the pandemic has exacerbated preexisting patient safety issues and created novel patient safety challenges in ICUs in the United States. METHODS We performed a national, multi-institutional, mixed-methods survey of critical care clinicians to elicit experiences related to patient safety during the pandemic. The survey was disseminated via email through the Society of Critical Care Medicine listserv. Data were reported as valid percentages, compared by COVID caseload and peak of the pandemic; free-text responses were analyzed and coded for themes. RESULTS We received 335 survey responses. On general patient safety, 61% felt that conditions were more hazardous when compared with the prepandemic period. Those who took care of mostly COVID-19 patients were more likely to perceive that care was more hazardous (odds ratio, 4.89; 95% CI, 2.49-9.59) compared with those who took care of mostly non-COVID-19 or no COVID-19 patients. In free-text responses, providers identified patient safety risks related to pandemic adaptations, such as ventilator-related lung injury, medication and diagnostic errors, oversedation, oxygen device removal, and falls. CONCLUSIONS Increased COVID-19 case burden was significantly associated with perceptions of a less safe patient care environment by frontline ICU clinicians. Results of the qualitative analysis identified specific patient safety hazards in ICUs across the United States as downstream consequences of hospital and provider strain during periods of the COVID-19 pandemic.
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Affiliation(s)
- Amanda Rosen
- From the Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital
| | - Danielle Carter
- From the Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital
| | - Jo R. Applebaum
- From the Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital
| | - William N. Southern
- Division of Hospital Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York
| | - Joseph Schwartz
- Department of Psychiatry and Behavioral Sciences, Stony Brook University, Stony Brook
- Department of Medicine, Columbia University Irving Medical Center
| | - Talea Cornelius
- Department of Medicine, Columbia University Irving Medical Center
| | - Rachel C. Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University
| | - Natalie H. Yip
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York
| | - Harold A. Pincus
- Department of Psychiatry and Irving Institute for Clinical and Translational Research, Columbia University
- New York State Psychiatric Institute
| | - Calvin Hwang
- Department of Medicine, Weill Cornell Medical College, New York
- New York-Presbyterian Hospital Queens, Queens
| | - Joseph Cooke
- Department of Medicine, Weill Cornell Medical College, New York
- New York-Presbyterian Hospital Queens, Queens
| | - Jason S. Adelman
- From the Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York
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Sirgo G, Olona M, Martín-Delgado MC, Gordo F, Trenado J, García M, Bodí M. Cross-cultural adaptation of the SCORE survey and evaluation of the impact of Real-Time Random Safety Audits in organizational culture: A multicenter study. Med Intensiva 2022; 46:568-576. [PMID: 36155679 DOI: 10.1016/j.medine.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/20/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To establish a cross-cultural adaptation of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey and to use this instrument to evaluate the impact of a safety intervention. DESIGN Cross-cultural adaptation and before-and-after evaluation study. SETTING 5 ICU. PARTICIPANTS Medical residents, attending physicians, and nurses at those ICU. INTERVENTIONS Adaptation of the SCORE survey to Spanish culture. The adapted survey was used to assess all safety-culture-related domains before and one-year after implementing the use of a safety tool, Real-Time Random Safety Audits (in Spanish: Análisis Aleatorios de Seguridad en Tiempo Real, AASTRE). MAIN OUTCOME MEASURE Adaptabiliy of the Spanish version of SCORE survey in the ICU setting and evaluation of the effect of AASTRE on their domains. RESULTS The cross-cultural adaptation was adequate. Post-AASTRE survey scores [mean (standard deviation, SD)] were significantly better in the domains learning environment [50.55 (SD 20.62) vs 60.76 (SD 23.66), p<.0001], perception of local leadership [47.98 (SD 23.57) vs 62.82 (SD 27.46), p<.0001], teamwork climate [51.19 (SD 18.55) vs 55.89 (SD 20.25), p=.031], safety climate [45.07 (SD 17.60) vs 50.36 (SD 19.65), p=.01], participation decision making [3 (SD 0.82) vs 3.65 (SD 0.87), p<.0001] and advancement in the organization [3.21 (SD 0.77) vs 4.04 (SD 0.77), p<.0001]. However, post-AASTRE scores were significantly worse in the domains workload and burnout climate. CONCLUSIONS The cross-cultural adaptation of the SCORE survey into Spanish is a useful tool for ICUs. The application of the AASTRE is associated with improvements in six SCORE domains, including the safety climate.
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Affiliation(s)
- G Sirgo
- Intensive Care Unit, University Hospital Joan XXIII, Pere Virgili Institute for Health Research, Rovira i Virgili University, Tarragona, Spain.
| | - M Olona
- Department of Preventive Medicine, University Hospital Joan XXIII, Rovira i Virgili University, Tarragona, Spain
| | - M C Martín-Delgado
- Intensive Care Unit, University Hospital Torrejón, Torrejón de Ardoz, Madrid, Spain
| | - F Gordo
- Intensive Care Unit, University Hospital Henares, Coslada, Madrid, Spain
| | - J Trenado
- Intensive Care Unit, University Hospital Mutua de Terrasa, Terrasa, Barcelona , Spain
| | - M García
- Intensive Care Unit, University Hospital Río Ortega, Valladolid, Spain
| | - M Bodí
- Intensive Care Unit, University Hospital Joan XXIII, Pere Virgili Institute for Health Research, Rovira i Virgili University, Tarragona, Spain
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Prower E, Hadfield S, Saha R, Woo T, Ang KM, Metaxa V. A critical care outreach team under strain - Evaluation of the service provided to patients with haematological malignancy during the Covid-19 pandemic. J Crit Care 2022; 71:154109. [PMID: 35843047 PMCID: PMC9282870 DOI: 10.1016/j.jcrc.2022.154109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/25/2022]
Abstract
Purpose Critical Care Outreach Teams (CCOTs) have been associated with improved outcomes in patients with haematological malignancy (HM). This study aims to describe CCOT activation by patients with HM before and during the Covid-19 pandemic, assess amny association with worse outcomes, and examine the psychological impact on the CCOT. Materials and methods A retrospective, mixed-methods analysis was performed in HM patients reviewed by the CCOT over a two-year period, 01 July 2019 to 31 May 2021. Results The CCOT increased in size during the surge period and reviewed 238 HM patients, less than in the pre- and post-surge periods. ICU admission in the baseline, surge and the non-surge periods were 41.7%, 10.4% and 47.9% respectively. ICU mortality was 22.5%, 0% and 21.7% for the same times. Time to review was significantly decreased (p = 0.012). Semi-structured interviews revealed four themes of psychological distress: 1) time-critical work; 2) non-evidence based therapies; 3) feelings of guilt; 4) increased decision-making responsibility. Conclusions Despite the increase in total hospital referrals, the number of patients with HM that were reviewed during the surge periods decreased, as did their ICU admission rate and mortality. The quality of care provided was not impaired, as reflected by the number of patients receiving bedside reviews and the shorter-than-pre-pandemic response time.
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Affiliation(s)
- Emma Prower
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Sophie Hadfield
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Rohit Saha
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy Woo
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Kar Mun Ang
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK.
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Vollam S, Gustafson O, Morgan L, Pattison N, Thomas H, Watkinson P. Patient Harm and Institutional Avoidability of Out-of-Hours Discharge From Intensive Care: An Analysis Using Mixed Methods. Crit Care Med 2022; 50:1083-1092. [PMID: 35245235 PMCID: PMC9197137 DOI: 10.1097/ccm.0000000000005514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night. DESIGN This study was part of the REcovery FoLlowing intensive CarE Treatment mixed methods study. We defined out-of-hours discharge as 16:00 to 07:59 hours. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged "probably avoidable" in previous retrospective structured judgment reviews, and 20 where patients survived. We conducted semistructured interviews with 55 patients, family members, and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the human factors-based functional analysis resonance method. SETTING Three U.K. National Health Service hospitals, chosen to represent different hospital settings. SUBJECTS Patients discharged from ICU, their families, and staff involved in their care. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable, and did not have deterioration recognized or escalated appropriately. We identified five interdependent function keys to facilitating timely ICU discharge: multidisciplinary team decision for discharge, patient prepared for discharge, bed meeting, bed manager allocation of beds, and ward bed made available. CONCLUSIONS We identified significant limitations in out-of-hours care provision following overnight discharge from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night.
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Affiliation(s)
- Sarah Vollam
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Owen Gustafson
- Oxford Allied Health Professions Research and Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Lauren Morgan
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Natalie Pattison
- School of Health and Social Work, University of Hertfordshire, Hatfield, United Kingdom
- East and North Herts NHS Trust, Stevenage, United Kingdom
| | - Hilary Thomas
- Centre for Research in Public Health and Community Care, School of Health and Social Work, University of Hertfordshire, Hatfield, United Kingdom
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Does Unprecedented ICU Capacity Strain, As Experienced During the COVID-19 Pandemic, Impact Patient Outcome? Crit Care Med 2022; 50:e548-e556. [PMID: 35170537 PMCID: PMC9112508 DOI: 10.1097/ccm.0000000000005464] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether patients admitted to an ICU during times of unprecedented ICU capacity strain, during the COVID-19 pandemic in the United Kingdom, experienced a higher risk of death. DESIGN Multicenter, observational cohort study using routine clinical audit data. SETTING Adult general ICUs participating the Intensive Care National Audit & Research Centre Case Mix Programme in England, Wales, and Northern Ireland. PATIENTS One-hundred thirty-thousand six-hundred eighty-nine patients admitted to 210 adult general ICUs in 207 hospitals. INTERVENTIONS Multilevel, mixed effects, logistic regression models were used to examine the relationship between levels of ICU capacity strain on the day of admission (typical low, typical, typical high, pandemic high, and pandemic extreme) and risk-adjusted hospital mortality. MEASUREMENTS AND MAIN RESULTS In adjusted analyses, compared with patients admitted during periods of typical ICU capacity strain, we found that COVID-19 patients admitted during periods of pandemic high or pandemic extreme ICU capacity strain during the first wave had no difference in hospital mortality, whereas those admitted during the pandemic high or pandemic extreme ICU capacity strain in the second wave had a 17% (odds ratio [OR], 1.17; 95% CI, 1.05-1.30) and 15% (OR, 1.15; 95% CI, 1.00-1.31) higher odds of hospital mortality, respectively. For non-COVID-19 patients, there was little difference in trend between waves, with those admitted during periods of pandemic high and pandemic extreme ICU capacity strain having 16% (OR, 1.16; 95% CI, 1.08-1.25) and 30% (OR, 1.30; 95% CI, 1.14-1.48) higher overall odds of acute hospital mortality, respectively. CONCLUSIONS For patients admitted to ICU during the pandemic, unprecedented levels of ICU capacity strain were significantly associated with higher acute hospital mortality, after accounting for differences in baseline characteristics. Further study into possible differences in the provision of care and outcome for COVID-19 and non-COVID-19 patients is needed.
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Mohr DC, Swamy L, Wong ES, Mealer M, Moss M, Rinne ST. Critical Care Nurse Burnout in Veterans Health Administration: Relation to Clinician and Patient Outcomes. Am J Crit Care 2021; 30:435-442. [PMID: 34719713 DOI: 10.4037/ajcc2021187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Critical care nurses have a burnout rate among the highest of any nursing field. Nurse burnout may impact care quality. Few studies have considered how temporal patterns may influence outcomes. OBJECTIVE To test a longitudinal model of burnout clusters and associations with patient and clinician outcomes. METHODS An observational study analyzed data from annual employee surveys and administrative data on patient outcomes at 111 Veterans Health Administration intensive care units from 2013 through 2017. Site-level burnout rates among critical care nurses were calculated from survey responses about emotional exhaustion and depersonalization. Latent trajectory analysis was applied to identify clusters of facilities with similar burnout patterns over 5 years. Regression analysis was used to analyze patient and employee outcomes by burnout cluster and organizational context measures. Outcomes of interest included patient outcomes (30-day standardized mortality rate and observed minus expected length of stay) for 2016 and 2017 and clinician outcomes (intention to leave and employee satisfaction) from 2013 through 2017. RESULTS Longitudinal analysis revealed 3 burnout clusters among the 111 sites: low (n = 37), medium (n = 68), and high (n = 6) burnout. Compared with sites in the low-burnout cluster, those in the high-burnout cluster had longer patient stays, higher employee turnover intention, and lower employee satisfaction in bivariate models but not in multivariate models. CONCLUSIONS In this multiyear, multisite study, critical care nurse burnout was associated with key clinician and patient outcomes. Efforts to address burnout among nurses may improve patient and employee outcomes.
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Affiliation(s)
- David C. Mohr
- David C. Mohr is an investigator, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, and a research assistant professor, Department of Health Policy and Management, Boston University School of Public Health, Boston
| | - Lakshmana Swamy
- Lakshmana Swamy was a pulmonary and critical care fellow at Boston Medical Center and VA Boston, Boston, Massachusetts; he is now an assistant professor, Population & Quantitative Health Sciences, UMass Medical School, Worcester, Massachusetts
| | - Edwin S. Wong
- Edwin S. Wong is a core investigator, Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Meredith Mealer
- Meredith Mealer is an associate professor of medicine, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Marc Moss
- Marc Moss is a professor of medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
| | - Seppo T. Rinne
- Seppo T. Rinne is an assistant professor, Pulmonary Center, Boston University School of Medicine, and a physician scientist, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
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Nassiff A, Menegueti MG, de Araújo TR, Auxiliadora-Martins M, Laus AM. Demand for Intensive Care beds and patient classification according to the priority criterion. Rev Lat Am Enfermagem 2021; 29:S0104-11692021000100384. [PMID: 34730765 PMCID: PMC8570257 DOI: 10.1590/1518-8345.4945.3489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 06/22/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE to assess the demand for Intensive Care Unit beds as well as the classification of the patients for admission, according to the priority system. METHOD a retrospective and cross-sectional study, developed from January2014 to December2018 in two Intensive Care Units for adults of a university hospital. The sample consisted of the requests for vacancies according to the priority system(scale from 1 to 4, where 1 is the highest priority and 4 is no priority), registered in the institution's electronic system. RESULTS a total of 8,483 vacancies were requested, of which 4,389(51.7%) were from unitB. The highest percentage in unitA was of Priority2 patients(32.6%); and Priority1 was prevalent in unitB(45.4%). The median lead time between request and admission to unitA presented a lower value for priority1 patients(2h57) and a higher value for priority4 patients(11h24); in unitB, priority4 patients presented shorter time(5h54) and priority3 had longer time(11h54). 40.5% of the requests made to unitA and 48.5% of those made to unitB were fulfilled, with 50.7% and 48.5% of these patients being discharged from the units, respectively. CONCLUSION it is concluded that the demand for intensive care beds was greater than their availability. Most of the patients assisted were priorities1 and2, although a considerable percentage of those classified as priorities3 and4 is observed.
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Affiliation(s)
- Aline Nassiff
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
| | - Mayra Gonçalves Menegueti
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
| | - Thamiris Ricci de Araújo
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
| | | | - Ana Maria Laus
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
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Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study. J Clin Med 2021; 10:jcm10143068. [PMID: 34300235 PMCID: PMC8305175 DOI: 10.3390/jcm10143068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. Objectives: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. Method: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient’s comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from −0.05 to 0.42 for patients with advanced disease, and from −0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. Conclusion: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.
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Sirgo G, Olona M, Martín-Delgado MC, Gordo F, Trenado J, García M, Bodí M. Cross-cultural adaptation of the SCORE survey and evaluation of the impact of Real-Time Random Safety Audits in organizational culture: A multicenter study. Med Intensiva 2021; 46:S0210-5691(21)00074-7. [PMID: 34052044 DOI: 10.1016/j.medin.2021.03.015] [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: 01/26/2021] [Revised: 03/09/2021] [Accepted: 03/20/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To establish a cross-cultural adaptation of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey and to use this instrument to evaluate the impact of a safety intervention. DESIGN Cross-cultural adaptation and before-and-after evaluation study. SETTING 5 ICU. PARTICIPANTS Medical residents, attending physicians, and nurses at those ICU. INTERVENTIONS Adaptation of the SCORE survey to Spanish culture. The adapted survey was used to assess all safety-culture-related domains before and one-year after implementing the use of a safety tool, Real-Time Random Safety Audits (in Spanish: Análisis Aleatorios de Seguridad en Tiempo Real, AASTRE). MAIN OUTCOME MEASURE Adaptabiliy of the Spanish version of SCORE survey in the ICU setting and evaluation of the effect of AASTRE on their domains. RESULTS The cross-cultural adaptation was adequate. Post-AASTRE survey scores [mean (standard deviation, SD)] were significantly better in the domains learning environment [50.55 (SD 20.62) vs 60.76 (SD 23.66), p<.0001], perception of local leadership [47.98 (SD 23.57) vs 62.82 (SD 27.46), p<.0001], teamwork climate [51.19 (SD 18.55) vs 55.89 (SD 20.25), p=.031], safety climate [45.07 (SD 17.60) vs 50.36 (SD 19.65), p=.01], participation decision making [3 (SD 0.82) vs 3.65 (SD 0.87), p<.0001] and advancement in the organization [3.21 (SD 0.77) vs 4.04 (SD 0.77), p<.0001]. However, post-AASTRE scores were significantly worse in the domains workload and burnout climate. CONCLUSIONS The cross-cultural adaptation of the SCORE survey into Spanish is a useful tool for ICUs. The application of the AASTRE is associated with improvements in six SCORE domains, including the safety climate.
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Affiliation(s)
- G Sirgo
- Intensive Care Unit, University Hospital Joan XXIII, Pere Virgili Institute for Health Research, Rovira i Virgili University, Tarragona, Spain.
| | - M Olona
- Department of Preventive Medicine, University Hospital Joan XXIII, Rovira i Virgili University, Tarragona, Spain
| | - M C Martín-Delgado
- Intensive Care Unit, University Hospital Torrejón, Torrejón de Ardoz, Madrid, Spain
| | - F Gordo
- Intensive Care Unit, University Hospital Henares, Coslada, Madrid, Spain
| | - J Trenado
- Intensive Care Unit, University Hospital Mutua de Terrasa, Terrasa, Barcelona , Spain
| | - M García
- Intensive Care Unit, University Hospital Río Ortega, Valladolid, Spain
| | - M Bodí
- Intensive Care Unit, University Hospital Joan XXIII, Pere Virgili Institute for Health Research, Rovira i Virgili University, Tarragona, Spain
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Harris GH, Rak KJ, Kahn JM, Angus DC, Mancing OR, Driessen J, Wallace DJ. US Hospital Capacity Managers' Experiences and Concerns Regarding Preparedness for Seasonal Influenza and Influenza-like Illness. JAMA Netw Open 2021; 4:e212382. [PMID: 33739431 PMCID: PMC7980097 DOI: 10.1001/jamanetworkopen.2021.2382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
IMPORTANCE The 2017-2018 influenza season in the US was marked by a high severity of illness, wide geographic spread, and prolonged duration compared with recent previous seasons, resulting in increased strain throughout acute care hospital systems. OBJECTIVE To characterize self-reported experiences and views of hospital capacity managers regarding the 2017-2018 influenza season in the US. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, semistructured telephone interviews were conducted between April 2018 and January 2019 with a random sample of capacity management administrators responsible for throughput and hospital capacity at short-term, acute care hospitals throughout the US. MAIN OUTCOMES AND MEASURES Each participant's self-reported experiences and views regarding high patient volumes during the 2017-2018 influenza season, lessons learned, and the extent of hospitals' preparedness planning for future pandemic events. Interviews were recorded and transcribed and then analyzed using thematic content analysis. Outcomes included themes and subthemes. RESULTS A total of 53 key hospital capacity personnel at 53 hospitals throughout the US were interviewed; 39 (73.6%) were women, 48 (90.6%) had a nursing background, and 29 (54.7%) had been in the occupational role for more than 4 years. Participants' experiences were categorized into several domains: (1) perception of strain, (2) effects of influenza and influenza-like illness on staff and patient care, (3) immediate staffing and capacity responses to influenza and influenza-like illness, and (4) future staffing and capacity preparedness for influenza and influenza-like illness. Participants reported experiencing perceived strain associated with concerns about preparedness for seasonal influenza and influenza-like illness as well as concerns about staffing, patient care, and capacity, but future pandemic planning within hospitals was not reported as being a high priority. CONCLUSIONS AND RELEVANCE The findings of this qualitative study suggest that during the 2017-2018 influenza season, there were systemic vulnerabilities as well as a lack of hospital preparedness planning for future pandemics at US hospitals. These issues should be addressed given the current coronavirus disease 2019 pandemic.
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Affiliation(s)
- Gavin H. Harris
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kimberly J. Rak
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Olivia R. Mancing
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Julia Driessen
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - David J. Wallace
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Du J, Gunnerson KJ, Bassin BS, Meldrum C, Hyzy RC. Effect of an emergency department intensive care unit on medical intensive unit admissions and care: A retrospective cohort study. Am J Emerg Med 2021; 46:27-33. [PMID: 33714051 DOI: 10.1016/j.ajem.2021.02.037] [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: 05/07/2020] [Revised: 01/23/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Evaluate the impact of an emergency critical care center (EC3) on the admissions of critically ill patients to a critical care medicine unit (CCMU) and their outcomes. METHODS This was a retrospective before/after cohort study in a tertiary university teaching hospital. To improve the care of critically ill patients in the emergency department (ED), a 9-bed EC3 was opened in the ED in February 2015. All critically ill patients in the emergency department must receive intensive support in EC3 before being considered for admission to the CCMU for further treatment. Patients from the emergency department account for a significant proportion of the patients admitted to the CCMU. The proportions of patients admitted to the CCMU from the ED were analyzed 1 year before and 1 year after the opening of the EC3. We also compared the admission data, demographic data, APACHE III scores and patient outcomes among patients admitted from ED to the CCMU in the year before and the year after the opening of the EC3. RESULT The establishment of the EC3 was associated with a decreased proportion of patients admitted to the CCMU from the ED (OR 0.73 95% CI 0.63-0.84, p < 0.01), a decrease in the proportion of patients with sepsis admitted from the ED (OR 0.68, 95% CI, 0.54-0.87, p < 0.01) and a decrease in the proportion of patients with gastrointestinal bleeding admitted from the ED (OR 0.49, 95% CI 0.28-0.84, p < 0.05). Following the establishment of the EC3, patients admitted to the CCMU had a higher APACHE III score in 2015 (74.85 ± 30.42 vs 72.39 ± 29.64, p = 0.015). Fewer low-risk patients were admitted to the CCMU for monitoring following the opening of the EC3 (112 [6.8%] vs. 181 [9.3%], p < 0.01). Propensity score matching analysis showed that the opening of the EC3 was associated with improved 60-day survival (HR 0.84, 95% CI 0.70-0.99, p = 0.046). CONCLUSION Following the opening of the EC3, the proportion of CCMU admissions from the ED decreased. The EC3 may be most effective at reducing the admission of lower-acuity patients with GI bleeding and possibly sepsis. The EC3 may be associated with improved survival in ED patients.
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Affiliation(s)
- Jiang Du
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA; Shanghai General Hospital of Shanghai Jiaotong University, Shanghai, China
| | - Kyle J Gunnerson
- Emergency Department, The University of Michigan Health System, MI, USA
| | - Benjamin S Bassin
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA
| | - Craig Meldrum
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA
| | - Robert C Hyzy
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA.
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Evaluation of Electronic Health Record-Generated Work Intensity Scores and Nurse Perceptions of Workload Appropriateness. Comput Inform Nurs 2020; 39:306-311. [PMID: 33346996 DOI: 10.1097/cin.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Electronic health record-generated work intensity scores represent state-of-the art functionality for dynamic nursing workload estimation in the hospital setting. In contrast to traditional stand-alone patient classification and acuity tools, electronic health record-based tools eliminate the need for dedicated data entry, and scores are automatically updated as new information is entered into patient records. This paper summarizes the method and results of evaluation of electronic health record-generated work intensity scores on six hospital patient care units in a single academic medical center. The correlation between beginning-of-shift work intensity scores and self-reported registered nurse rating of appropriateness of patient assignment was assessed using Spearman rank correlation. A weak negative correlation (-0.09 to -0.23) was observed on all study units, indicating that nurse appropriateness ratings decrease as work intensity scores increase. Electronic health record-generated work intensity scores provide useful information that can augment existing data sources used by charge nurses to create equitable nurse-patient assignments. Additional research is needed to explain observed variation in nurses' appropriateness ratings across similar work intensity point ranges.
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Bagshaw SM, Tran DT, Opgenorth D, Wang X, Zuege DJ, Ingolfsson A, Stelfox HT, Thanh NX. Assessment of Costs of Avoidable Delays in Intensive Care Unit Discharge. JAMA Netw Open 2020; 3:e2013913. [PMID: 32822492 PMCID: PMC7439109 DOI: 10.1001/jamanetworkopen.2020.13913] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Delays in transfer for discharge-ready patients from the intensive care unit (ICU) are increasingly described and contribute to strained capacity. OBJECTIVE To describe the epidemiological features and health care costs attributable to potentially avoidable delays in ICU discharge in a large integrated health care system. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study was performed in 17 adult ICUs in Alberta, Canada, from June 19, 2012, to December 31, 2016. Participants were patients 15 years or older admitted to a study ICU during the study period. Data were analyzed from October 19, 2018, to May 20, 2020. EXPOSURES Avoidable time in the ICU, defined as the portion of total ICU patient-days accounted for by avoidable delay in ICU discharge (eg, waiting for a ward bed). MAIN OUTCOMES AND MEASURES The primary outcome was health care costs attributable to avoidable time in the ICU. Secondary outcomes were factors associated with avoidable time, in-hospital mortality, and measures of use of health care resources, including the number of hours in the ICU and the number of days of hospitalization. Multilevel mixed multivariable regression was used to assess associations between avoidable time and outcomes. RESULTS In total, 28 904 patients (mean [SD] age, 58.3 [16.8] years; 18 030 male [62.4%]) were included. Of these, 19 964 patients (69.1%) had avoidable time during their ICU admission. The median avoidable time per patient was 7.2 (interquartile range, 2.4-27.7) hours. In multivariable analysis, male sex (odds ratio [OR], 0.92; 95% CI, 0.87-0.98), comorbid hemiplegia or paraplegia (OR 1.47; 95% CI, 1.23-1.75), liver disease (OR 1.20; 95% CI, 1.04-1.37), admission Acute Physiology and Chronic Health Evaluation II score (OR, 1.03; 95% CI, 1.02-1.03), surgical status (OR, 0.90; 95% CI, 0.82-0.98), medium community hospital type (OR, 0.12; 95% CI, 0.04-0.32), and admission year (OR, 1.16; 95% CI, 1.13-1.19) were associated with avoidable time. The cumulative avoidable time was 19 373.9 days, with estimated attributable costs of CAD$34 323 522. Avoidable time accounted for 12.8% of total ICU bed-days and 6.4% of total ICU costs. Patients with avoidable time before ICU discharge showed higher unadjusted in-hospital mortality (1115 [5.6%] vs 392 [4.4%]; P < .001); however, in multivariable analysis, avoidable time was associated with reduced in-hospital mortality (adjusted hazard ratio, 0.74; 95% CI, 0.64-0.85). Results were similar in sensitivity analyses. CONCLUSIONS AND RELEVANCE In this study, potentially avoidable discharge delay occurred for most patients admitted to ICUs across a large integrated health system and translated into substantial associated health care costs.
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Affiliation(s)
- Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Canada
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Dat T. Tran
- Institute of Health Economics, Edmonton, Alberta, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Xiaoming Wang
- Health Services Statistical and Analytic Methods, Alberta Health Services, Edmonton, Canada
| | - Danny J. Zuege
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Alberta Health Services, Calgary, Canada
| | | | - Henry T. Stelfox
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Alberta Health Services, Calgary, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nguyen X. Thanh
- School of Public Health, University of Alberta, Edmonton, Canada
- Strategic Clinical Networks, Alberta Health Services, Edmonton, Canada
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Kong DK, Kong AM, Wasserman I, Villavisanis DF, Hackett AM. Ambulatory tonsillectomy for children with severe obstructive sleep apnea without risk factors. Am J Otolaryngol 2020; 41:102467. [PMID: 32234256 DOI: 10.1016/j.amjoto.2020.102467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/24/2020] [Accepted: 03/15/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Recommendations for polysomnography (PSG) in pediatric sleep disordered breathing (SDB) vary between the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the American Academy of Pediatrics (AAP). We determined the rates of preoperative PSG in children without risk factors outlined in the AAO-HNS Clinical Practice Guidelines and described the postoperative course of those patients following T&A. METHODS Patients aged 3-17 undergoing T&A for SDB or OSA who did not have an indication for preoperative PSG were included. We conducted retrospective review to describe the rate, type, and timing of respiratory complications for patients with and without PSG following T&A, and discuss cases where disposition was changed due to PSG results. RESULTS 1135 patients without risk factors underwent T&A for SDB or OSA. 196 (17%) had a preoperative PSG, of whom 85 (43.3%) had AHI >10 and 38 (24.8%) had an O2 nadir <80%. 69 (85%) patients with PSG-diagnosed severe OSA were admitted overnight. Of the entire cohort, 5 patients (0.44%) had hypoxemia requiring blow-by oxygen or repositioning. 4 (0.43%) patients without PSG experienced respiratory events and were converted to overnight stay. The timing of respiratory events for all children ranged from immediately following extubation in the operating room to 3 h postoperatively. CONCLUSION PSG in children without risk factors results in admission of otherwise healthy patients following T&A who would have otherwise undergone ambulatory surgery. PSG alone in pediatric patients with no AAO-HNS risk factors should not influence postoperative disposition. These patients should be monitored for 3 h post-T&A and discharged in the absence of complications. EVIDENCE LEVEL 2b.
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Affiliation(s)
- Derek K Kong
- Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | | | | | | | - Alyssa M Hackett
- Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Bowker SL, Stelfox HT, Bagshaw SM. Critical Care Strategic Clinical Network: Information infrastructure ensures a learning health system. CMAJ 2020; 191:S22-S23. [PMID: 31801758 DOI: 10.1503/cmaj.190578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Samantha L Bowker
- Critical Care Strategic Clinical Network (Bowker, Stelfox, Bagshaw), Alberta Health Services; Department of Critical Care Medicine, Faculty of Medicine and Dentistry (Bowker, Bagshaw), University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alta
| | - Henry T Stelfox
- Critical Care Strategic Clinical Network (Bowker, Stelfox, Bagshaw), Alberta Health Services; Department of Critical Care Medicine, Faculty of Medicine and Dentistry (Bowker, Bagshaw), University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alta
| | - Sean M Bagshaw
- Critical Care Strategic Clinical Network (Bowker, Stelfox, Bagshaw), Alberta Health Services; Department of Critical Care Medicine, Faculty of Medicine and Dentistry (Bowker, Bagshaw), University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alta.
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22
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Cherney RL, Pandian V, Ninan A, Eastman D, Barnes B, King E, Miller B, Judkins S, Smith AE, Smith NM, Hanley J, Creutz E, Carlson M, Schneider KJ, Shever LL, Casper KA, Davidson PM, Brenner MJ. The Trach Trail: A Systems-Based Pathway to Improve Quality of Tracheostomy Care and Interdisciplinary Collaboration. Otolaryngol Head Neck Surg 2020; 163:232-243. [PMID: 32450771 DOI: 10.1177/0194599820917427] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To implement a standardized tracheostomy pathway that reduces length of stay through tracheostomy education, coordinated care protocols, and tracking patient outcomes. METHODS The project design involved retrospective analysis of a baseline state, followed by a multimodal intervention (Trach Trail) and prospective comparison against synchronous controls. Patients undergoing tracheostomy from 2015 to 2016 (n = 60) were analyzed for demographics and outcomes. Trach Trail, a standardized care pathway, was developed with the Iowa Model of Evidence-Based Practice. Trach Trail implementation entailed monthly tracheostomy champion training at 8-hour duration and staff nurse didactics, written materials, and experiential learning. Trach Trail enrollment occurred from 2018 to 2019. Data on demographics, length of stay, and care outcomes were collected from patients in the Trach Trail group (n = 21) and a synchronous tracheostomy control group (n = 117). RESULTS Fifty-five nurses completed Trach Trail training, providing care for 21 patients placed on the Trach Trail and for synchronous control patients with tracheostomy who received routine tracheostomy care. Patients on the Trach Trail and controls had similar demographic characteristics, diagnoses, and indications for tracheostomy. In the Trach Trail group, intensive care unit length of stay was significantly reduced as compared with the control group, decreasing from a mean 21 days to 10 (P < .05). The incidence of adverse events was unchanged. DISCUSSION Introduction of the Trach Trail was associated with a reduction in length of stay in the intensive care unit. Realizing broader patient-centered improvement likely requires engaging respiratory therapists, speech language pathologists, and social workers to maximize patient/caregiver engagement. IMPLICATIONS FOR PRACTICE Standardized tracheostomy care with interdisciplinary collaboration may reduce length of stay and improve patient outcomes.
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Affiliation(s)
- Rebecca L Cherney
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | | | - Ashly Ninan
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Debra Eastman
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Brian Barnes
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Elizabeth King
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Brianne Miller
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Samantha Judkins
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Alfred E Smith
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA
| | - Nan M Smith
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA
| | - Julie Hanley
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Eileen Creutz
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Megan Carlson
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Kevin J Schneider
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Leah L Shever
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | | | - Michael J Brenner
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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23
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Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
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Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
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Womack DM, Vuckovic NN, Steege LM, Eldredge DH, Hribar MR, Gorman PN. Subtle cues: Qualitative elicitation of signs of capacity strain in the hospital workplace. APPLIED ERGONOMICS 2019; 81:102893. [PMID: 31422247 PMCID: PMC6834115 DOI: 10.1016/j.apergo.2019.102893] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 06/20/2019] [Accepted: 07/03/2019] [Indexed: 06/10/2023]
Abstract
Through everyday care experiences, nurses develop expertise in recognition of capacity strain in hospital workplaces. Through qualitative interview, experienced nurses identify common activity changes and adaptive work strategies that may signal an imbalance between patient demand and service supply at the bedside. Activity change examples include nurse helping behaviors across patient assignments, increased volume of nurse calls from patient rooms, and decreased presence of staff at the nurses' station. Adaptive work strategies encompass actions taken to recruit resources, move work in time, reduce work demands, or reduce thoroughness of task performance. Nurses' knowledge of perceptible signs of strain provides a foundation for future exploration and development of real-time indicators of capacity strain in hospital-based work systems.
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Affiliation(s)
- Dana M Womack
- Oregon Health & Science University, Department of Medical Informatics & Clinical Epidemiology, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239-3098, USA.
| | - Nancy N Vuckovic
- Cambia Health Solutions, 100 SW Market St, Portland, OR, 97201, USA
| | - Linsey M Steege
- University of Wisconsin - Madison, School of Nursing, 701 Highland Avenue, Madison, WI, 53705, USA
| | - Deborah H Eldredge
- Oregon Health & Science University Hospital, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239-3098, USA
| | - Michelle R Hribar
- Oregon Health & Science University, Department of Medical Informatics & Clinical Epidemiology, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239-3098, USA
| | - Paul N Gorman
- Oregon Health & Science University, Department of Medical Informatics & Clinical Epidemiology, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239-3098, USA; Oregon Health & Science University Hospital, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239-3098, USA
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Anstey MH, Gershengorn HB, Hawryluck L. "Hang on, I haven't seen this patient yet…": near simultaneous admissions to the ICU. Intensive Care Med 2019; 45:1642-1644. [PMID: 31588981 DOI: 10.1007/s00134-019-05778-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 09/03/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia. .,School of Medicine, University of Western Australia, Perth, Australia.
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Laura Hawryluck
- Interdepartmental Critical Care Medicine, University of Toronto, MSNICU Toronto Western Hospital, University Health Network Canada, Toronto, Canada
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26
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Fleischmann-Struzek C, Mikolajetz A, Reinhart K, Curtis RJ, Haase U, Thomas-Rüddel D, Dennler U, Hartog CS. Hospitalization and Intensive Therapy at the End of Life. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:653-660. [PMID: 31617481 PMCID: PMC6832106 DOI: 10.3238/arztebl.2019.0653] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 01/29/2019] [Accepted: 07/08/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Germany has more intensive care unit (ICU) beds per capita than the USA, but the utilization of these resources at the end of life is unknown. METHODS Retrospective observational study using nationwide German hospital discharge data (DRG statistics; DRG, diag- nosis-related groups) from 2007 to 2015. We investigated hospital deaths and use of intensive care services during terminal hospitalizations. Population-based incidences were standardized to the age and sex distribution of the German population. RESULTS Standardized hospital admission rates increased by 0.8% annually (from 201.9 to 214.6 per 1000 population), while hospital admissions involving ICU care increased by 3.0% annually (from 6.5 to 8.2 per 1000 population). Among all deaths in the German population, the proportion of hospital deaths with ICU care increased by 2.3% annually (from 9.8% to 11.8%). Among all hospital deaths, the proportion involving ICU care increased by 2.8% annually from 20.6% (2007) to 25.6% (2015). In patients aged 65 and older, the use of intensive care services during terminal hospitalizations increased 3 times faster than hospital deaths. CONCLUSION Use of intensive care services during terminal hospitalizations increased across all age groups, particularly the elderly. The increased need for end-of-life care in the ICU calls for improvements in educational, policy, and reimbursement strategies. It is unclear whether ICU care was appropriate and compliant with patient preferences.
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Affiliation(s)
- Carolin Fleischmann-Struzek
- Center for Sepsis Control and Care, University Hospital Jena; Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena; BIH Guest Professorship/Charité Foundation, Department of Anesthesiology and Intensive Care Medicine, Charité University Medical Center, Berlin; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA; Department of Anesthesiology and Intensive Care Medicine, Charité University Medical Center, Berlin; Medical Controlling Division, Munich Hospital; Bavaria Hospital, Kreischa
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27
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Near-simultaneous intensive care unit (ICU) admissions and all-cause mortality: a cohort study. Intensive Care Med 2019; 45:1559-1569. [PMID: 31531716 DOI: 10.1007/s00134-019-05753-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 08/19/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE Prior studies have reported the adverse effects of strain on patient outcomes. There is a paucity of literature about a type of strain that may be caused by near-simultaneous intensive care unit (ICU) admissions. We hypothesized that when multiple admissions arrive nearly at the same time, the ICU teams are excessively strained, and this leads to unfavorable patient outcomes. METHODS This is a retrospective cohort study of consecutive adult patients admitted to an academic medical ICU of a tertiary referral center over five consecutive years. Primary outcomes were the all-cause hospital and ICU mortality. RESULTS We enrolled 13,234 consecutive ICU admissions during the study period. One-fourth of the admissions had an elapsed time since the last admission (ETLA) of < 55 min. Near-simultaneous admissions (NSA) had on average, a higher unadjusted odds ratio (OR) of ICU death of 1.16 (95% CI 1-1.35, P = 0.05), adjusted 1.23 (95% CI 1.04-1.44, P = 0.01), unadjusted hospital death of 1.11 (95% CI 0.99-1.24, P = 0.06), adjusted 1.20 (95% 1.05-1.35, P = 0.004), and a lower adjusted OR of home discharge of 0.91 (95% CI 0.84-0.99, P = 0.04). NSA was associated with 0.16 (95% CI 0.04-0.29, P = 0.01) added days in the ICU. For each incremental unit increase of the logarithmic transformation of ETLA [log (ETLA in minutes)], the average adjusted hospital mortality OR incrementally decreased by an added average OR of 0.93 (95% CI 0.89‒0.97, P = 0.001). CONCLUSION Our results suggest that near-simultaneous ICU admissions (NSA) are frequent and are associated with a dose-dependent effect on mortality, length of stay, and odds of home versus nursing facility discharge.
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28
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Intensive care unit length of stay is reduced by protocolized family support intervention: a systematic review and meta-analysis. Intensive Care Med 2019; 45:1072-1081. [PMID: 31270579 DOI: 10.1007/s00134-019-05681-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/26/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE This study aimed to elucidate the impact of protocolized family support intervention on length of stay (LOS) in the intensive care unit (ICU) through a systematic review and meta-analysis. METHODS Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and other web-based databases were referenced since inception until November 26, 2018. We included randomized-controlled trials wherein protocolized family support interventions were conducted for enhanced communication and shared medical decision-making. LOS (in days) and mortality were evaluated using a random-effects model, and adjusted LOS was estimated using a mixed-effects model. RESULTS We included seven randomized-controlled trials with 3477 patients. Protocolized family support interventions were found to significantly reduce the ICU LOS {mean difference = - 0.89 [95% confidence interval (CI) = - 1.50 to - 0.27]} and hospital LOS [mean difference = - 3.78 (95% CI = - 5.26 to - 2.29)]; the results of the mixed-effect model showed that they significantly reduced ICU LOS after adjusting for the therapeutic goal [mean difference = - 1.30 (95% CI = - 2.35 to - 0.26)], methods of measurement [mean difference = - 0.89 (95% CI = - 1.55 to - 0.22)], and timing of intervention [mean difference = - 1.05 (95% CI = - 2.05 to - 0.05)]. Similar results were found after adjusting for patients' disease severity [mean difference = - 1.21 (95% CI = - 2.03 to - 0.39)] and the trim-and-fill method [mean difference = - 0.86 (95% CI = - 1.44 to - 0.28)]. There was no difference in mortality rate in ICU and hospital between the protocolized intervention and control groups. CONCLUSIONS Protocolized family support intervention for enhanced communication and shared decision-making with the family reduced ICU LOS in critically ill patients without impacting mortality.
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29
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Time of admission to intensive care unit, strained capacity, and mortality: A retrospective cohort study. J Crit Care 2019; 54:1-6. [PMID: 31306832 DOI: 10.1016/j.jcrc.2019.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE We sought to study the association between afterhours ICU admission and ICU mortality considering measures of strained ICU capacity. MATERIALS AND METHODS Retrospective analysis of 4141 admissions to 2 ICUs in Lisbon, Portugal (06/2016-06/2018). Primary exposure was ICU admission on 20:00 h-07:59 h. Primary outcome was ICU mortality. Measures of strained ICU capacity were: bed occupancy rate ≥ 90% and cluster of ICU admissions 2 h before or following index admission. RESULTS There were 1581 (38.2%) afterhours ICU admissions. Median APACHE II score (19 vs. 20) was similar between patients admitted afterhours and others (P = .27). Patients admitted afterhours had higher crude ICU mortality (15.4% vs. 21.9%; P < .001), but similar adjusted ICU mortality (aOR [95%CI] = 1.15 [0.97-1.38]; P = .12). While bed occupancy rate ≥ 90% was more frequent in patients admitted afterhours (23.1% vs. 29.1%) or deceased in ICU (23.6% vs. 33.7%), cluster of ICU admissions was more frequent in patients admitted during daytime hours (75.2% vs. 58.9%) or that survived the ICU stay (70.1% vs. 63.9%; P ≤ .001 for all). These measures of strained ICU capacity were not associated with adjusted ICU mortality (P ≥ .10 for both). CONCLUSIONS Afterhours ICU admission and measures of strained ICU capacity were associated with crude but not adjusted ICU mortality.
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Tran DT, Thanh NX, Opgenorth D, Wang X, Zuege D, Zygun DA, Stelfox HT, Bagshaw SM. Association between strained ICU capacity and healthcare costs in Canada: A population-based cohort study. J Crit Care 2019; 51:175-183. [PMID: 30852346 DOI: 10.1016/j.jcrc.2019.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 02/11/2019] [Accepted: 02/25/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intensive care is resource intensive, with costs representing a substantial quantity of total hospitalization costs. Strained ICU capacity compromises care quality and adversely impacts outcomes; however, the association between strain and healthcare costs has not been explored. MATERIALS AND METHODS Population-based cohort study performed in 17 adult ICUs in Alberta, Canada. Data were captured on hospitalizations, ambulatory care, physician services and drug dispenses occurring 1-year before and 1-year after index ICU admission. Strain was defined as occupancy ≥90%; with 21 additional definitions evaluated. Patients were categorized as strain and non-strain admissions. Costs attributable to strain, were calculated as difference-in-difference costs using propensity-score matching. RESULTS 30,557 patients were included (strain: 11,830 [38.7%]; non-strain: 18,727 [61.3%]). At 1-year, strain admissions had adjusted-incremental per-patient cost of CA$9406 (95%CI, $5654-13,157) compared to non-strain admissions, due to hospitalization costs (CA$7930; 95%CI, $4553-11,307) and physician claims (CA$844; 95%CI, $430-1259). This equated to CA$111.3 million (95%CI, $66.9-155.6 million) in excess attributable costs. Strain portended longer hospitalization (3.3 days; 95%CI, 1.1-5.5); and more ambulatory visits (1.0; 95%CI, 0.1-2.0) and physician claims (9.5; 95%CI, 6.2-12.7). Incremental costs were robust across strain definitions. CONCLUSIONS Admissions to ICUs experiencing strain incur incremental costs, attributed to longer hospitalization and physician services.
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Affiliation(s)
- Dat T Tran
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Nguyen X Thanh
- Institute of Health Economics, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Research Facilitation, Analytics (DIMR), Alberta Health Services, Edmonton, Canada
| | - Danny Zuege
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - David A Zygun
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Henry T Stelfox
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada.
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Escher M, Cullati S, Hudelson P, Nendaz M, Ricou B, Perneger T, Dayer P. Admission to intensive care: A qualitative study of triage and its determinants. Health Serv Res 2018; 54:474-483. [PMID: 30362106 DOI: 10.1111/1475-6773.13076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine physicians' decision making and its determinants about admission to intensive care. DATA SOURCES/STUDY SETTING ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. STUDY DESIGN We conducted in-depth interviews. DATA COLLECTION/EXTRACTION METHODS Interviews were analyzed using an inductive thematic approach. PRINCIPAL FINDINGS Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. CONCLUSIONS Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Patricia Hudelson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Bara Ricou
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
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Stelfox HT, Soo A, Niven DJ, Fiest KM, Wunsch H, Rowan KM, Bagshaw SM. Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study. JAMA Intern Med 2018; 178:1390-1399. [PMID: 30128550 PMCID: PMC6584269 DOI: 10.1001/jamainternmed.2018.3675] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown. OBJECTIVE To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. DESIGN, SETTING, AND PARTICIPANTS Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics. EXPOSURES Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. MAIN OUTCOMES AND MEASURES The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. RESULTS Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35). CONCLUSIONS AND RELEVANCE The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.
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Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesia and Interdisciplinary Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, England
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
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Boyd JM, Roberts DJ, Parsons Leigh J, Stelfox HT. Administrator Perspectives on ICU-to-Ward Transfers and Content Contained in Existing Transfer Tools: a Cross-sectional Survey. J Gen Intern Med 2018; 33:1738-1745. [PMID: 30051330 PMCID: PMC6153252 DOI: 10.1007/s11606-018-4590-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/20/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The transfer of critically ill patients from the intensive care unit (ICU) to hospital ward is challenging. Shortcomings in the delivery of care for patients transferred from the ICU have been associated with higher healthcare costs and poor satisfaction with care. Little is known about how hospital ward providers, who accept care of these patients, perceive current transfer practices nor which aspects of transfer they perceive as needing improvement. OBJECTIVE To compare ICU and ward administrator perspectives regarding ICU-to-ward transfer practices and evaluate the content of transfer tools. DESIGN Cross-sectional survey design. PARTICIPANTS We administered a survey to 128 medical and/or surgical ICU and 256 ward administrators to obtain institutional perspectives on ICU transfer practices. We performed qualitative content analysis on ICU transfer tools received from respondents. KEY RESULTS In total, 108 (77%) ICU and 160 (63%) ward administrators responded to the survey. The ICU attending physician was reported to be "primarily responsible" for the safety (93% vs. 91%; p = 0.515) of patient transfers. ICU administrators more commonly perceived discharge summaries to be routinely included in patient transfers than ward administrators (81% vs. 60%; p = 0.006). Both groups identified information provided to patients/families, patient/family participation during transfer, and ICU-ward collaboration as opportunities for improvement. A minority of hospitals used ICU-to-ward transfer tools (11%) of which most (n = 21 unique) were designed to communicate patient information between providers (71%) and comprised six categories of information: demographics, patient clinical course, corrective aids, mobility at discharge, review of systems, and documentation of transfer procedures. CONCLUSION ICU and ward administrators have similar perspectives of transfer practices and identified patient/family engagement and communication as priorities for improvement. Key information categories exist.
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Affiliation(s)
- Jamie M Boyd
- Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Derek J Roberts
- Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Jeanna Parsons Leigh
- Departments of Critical Care Medicine, O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, Alberta, Canada.
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Perspectives on strained intensive care unit capacity: A survey of critical care professionals. PLoS One 2018; 13:e0201524. [PMID: 30133479 PMCID: PMC6104911 DOI: 10.1371/journal.pone.0201524] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 06/18/2018] [Indexed: 01/09/2023] Open
Abstract
Background Strained intensive care unit (ICU) capacity represents a supply-demand mismatch in ICU care. Limited data have explored health care worker (HCW) perceptions of strain. Methods Cross-sectional survey of HCW across 16 Alberta ICUs. A web-based questionnaire captured data on demographics, strain definition, and sources, impact and strategies for management. Results 658 HCW responded (33%; 95%CI, 32–36%), of which 452 were nurses (69%), 128 allied health (19%), 45 physicians (7%) and 33 administrators (5%). Participants (agreed/strongly agreed: 94%) reported that strain was best defined as “a time-varying imbalance between the supply of available beds, staff and/or resources and the demand to provide high-quality care for patients who may become or who are critically ill”; while some recommended defining “high-quality care”, integrating “safety”, and families in the definition. Participants reported significant contributors to strain were: “inability to discharge ICU patients due to lack of available ward beds” (97%); “increases in the volume” (89%); and “acuity and complexity of patients requiring ICU support” (88%). Strain was perceived to “increase stress levels in health care providers” (98%); and “burnout in health care providers” (96%). The highest ranked strategies were: “have more consistent and better goals-of-care conversations with patients/families outside of ICU” (95%); and “increase non-acute care beds” (92%). Interpretation Strain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies “outside” of ICU settings were priorities for managing strain.
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Association between afterhours admission to the intensive care unit, strained capacity, and mortality: a retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:97. [PMID: 29665826 PMCID: PMC5905119 DOI: 10.1186/s13054-018-2027-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/03/2018] [Indexed: 02/07/2023]
Abstract
Background Admission to the intensive care unit (ICU) outside daytime hours has been shown to be variably associated with increased morbidity and mortality. We aimed to describe the characteristics and outcomes of patients admitted to the ICU afterhours (22:00–06:59 h) in a large Canadian health region. We further hypothesized that the association between afterhours admission and mortality would be modified by indicators of strained ICU capacity. Methods This is a population-based cohort study of 12,265 adults admitted to nine ICUs in Alberta from June 2012 to December 2014. We used a path-analysis modeling strategy and mixed-effects multivariate regression analysis to evaluate direct and integrated associations (mediated through Acute Physiology and Chronic Health Evaluation (APACHE) II score) between afterhours admission (22:00–06:59 h) and ICU mortality. Further analysis examined the effects of strained ICU capacity and varied definitions of afterhours and weekend admissions. ICU occupancy ≥ 90% or clustering of admissions (≥ 0.15, defined as number of admissions 2 h before or after the index admission, divided by the number of ICU beds) were used as indicators of strained capacity. Results Of 12,265 admissions, 34.7% (n = 4251) occurred afterhours. The proportion of afterhours admissions varied amongst ICUs (range 26.7–37.8%). Patients admitted afterhours were younger (median (IQR) 58 (44–70) vs 60 (47–70) years, p < 0.0001), more likely to have a medical diagnosis (75.9% vs 72.1%, p < 0.0001), and had higher APACHE II scores (20.9 (8.6) vs 19.9 (8.3), p < 0.0001). Crude ICU mortality was greater for those admitted afterhours (15.9% vs 14.1%, p = 0.007), but following multivariate adjustment there was no direct or integrated effect on ICU mortality (odds ratio (OR) 1.024; 95% confidence interval (CI) 0.923–1.135, p = 0.658). Furthermore, direct and integrated analysis showed no association of afterhours admission and hospital mortality (p = 0.90) or hospital length of stay (LOS) (p = 0.27), although ICU LOS was shorter (p = 0.049). Early-morning admission (00:00–06:59 h) with ICU occupancy ≥ 90% was associated with short-term (≤ 7 days) and all-cause ICU mortality. Conclusions One-third of critically ill patients are admitted to the ICU afterhours. Afterhours ICU admission was not associated with greater mortality risk in most circumstances but was sensitive to strained ICU capacity. Electronic supplementary material The online version of this article (10.1186/s13054-018-2027-8) contains supplementary material, which is available to authorized users.
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Rewa OG, Stelfox HT, Ingolfsson A, Zygun DA, Featherstone R, Opgenorth D, Bagshaw SM. Indicators of intensive care unit capacity strain: a systematic review. Crit Care 2018; 22:86. [PMID: 29587816 PMCID: PMC5870068 DOI: 10.1186/s13054-018-1975-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Strained intensive care unit (ICU) capacity represents a fundamental supply-demand mismatch in ICU resources. Strain is likely to be influenced by a range of factors; however, there has been no systematic evaluation of the spectrum of measures that may indicate strain on ICU capacity. METHODS We performed a systematic review to identify indicators of strained capacity. A comprehensive peer-reviewed search of MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science Core Collection was performed along with selected grey literature sources. We included studies published in English after 1990. We included studies that: (1) focused on ICU settings; (2) included description of a quality or performance measure; and (3) described strained capacity. Retrieved studies were screened, selected and extracted in duplicate. Quality was assessed using the Newcastle-Ottawa Quality Assessment Scale (NOS). Analysis was descriptive. RESULTS Of 5297 studies identified in our search; 51 fulfilled eligibility. Most were cohort studies (n = 39; 76.5%), five (9.8%) were case-control, three (5.8%) were cross-sectional, two (3.9%) were modeling studies, one (2%) was a correlational study, and one (2%) was a quality improvement project. Most observational studies were high quality. Sixteen measures designed to indicate strain were identified 110 times, and classified as structure (n = 4, 25%), process (n = 7, 44%) and outcome (n = 5, 31%) indicators, respectively. The most commonly identified indicators of strain were ICU acuity (n = 21; 19.1% [process]), ICU readmission (n = 18; 16.4% [outcome]), after-hours discharge (n = 15; 13.6% [process]) and ICU census (n = 13; 11.8% [structure]). There was substantial heterogeneity in the operational definitions used to define strain indicators across studies. CONCLUSIONS We identified and characterized 16 indicators of strained ICU capacity across the spectrum of healthcare quality domains. Future work should aim to evaluate their implementation into practice and assess their value for evaluating strategies to mitigate strain. SYSTEMATIC REVIEW REGISTRATION This systematic review was registered at PROSPERO (March 27, 2015; CRD42015017931 ).
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Affiliation(s)
- Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 8440 - 112th Street, Edmonton, AB, T6G 2B7, Canada. .,School of Public Health, University of Alberta, Edmonton, AB, Canada.
| | - Henry T Stelfox
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Armann Ingolfsson
- Alberta School of Business, University of Alberta, Edmonton, AB, Canada
| | - David A Zygun
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 8440 - 112th Street, Edmonton, AB, T6G 2B7, Canada.,School of Public Health, University of Alberta, Edmonton, AB, Canada.,Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Robin Featherstone
- Alberta Research Center for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 8440 - 112th Street, Edmonton, AB, T6G 2B7, Canada.,Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 8440 - 112th Street, Edmonton, AB, T6G 2B7, Canada.,School of Public Health, University of Alberta, Edmonton, AB, Canada.,Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
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Bagshaw SM, Wang X, Zygun DA, Zuege D, Dodek P, Garland A, Scales DC, Berthiaume L, Faris P, Chen G, Opgenorth D, Stelfox HT. Association between strained capacity and mortality among patients admitted to intensive care: A path-analysis modeling strategy. J Crit Care 2018; 43:81-87. [DOI: 10.1016/j.jcrc.2017.08.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/18/2017] [Accepted: 08/19/2017] [Indexed: 01/09/2023]
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Abstract
OBJECTIVES We sought to 1) evaluate how pediatricians approach situations in which families request continuation of organ support after declaration of death by neurologic criteria and 2) explore potential interventions to make these situations less challenging. DESIGN A survey on management and personal experience with death by neurologic criteria was distributed electronically to pediatric intensivists and neurologists. We compared responses from individuals who practice in states with accommodation exceptions (accommodation states where religious or moral beliefs must be taken into consideration when declaring death: California, Illinois, New Jersey, New York) to those from non-accommodation states. SETTING United States. SUBJECTS The survey was opened by 254 recipients, with 186 meeting inclusion criteria and providing data about the region in which they practice; of these, 26% were from accommodation states. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS More than half of physicians (61% from both accommodation states and non-accommodation states) reported they cared for a pediatric patient whose family requested continuation of organ support after declaration of death by neurologic criteria (outside of organ donation; range, 1-17 times). Over half of physicians (53%) reported they would not feel comfortable handling a situation in which a pediatric patient's family requested care be continued after declaration of death by neurologic criteria. Nearly every physician (98%) endorsed that something needs to be done to make situations involving families who object to discontinuation of organ support after declaration of death by neurologic criteria easier to handle. Respondents felt that public education, physician education, and uniform state laws about these situations are warranted. CONCLUSIONS It is relatively common for pediatricians who care for critically ill patients to encounter families who object to discontinuation of organ support after death by neurologic criteria. Management of these situations is challenging, and guidance for medical professionals and the public is needed.
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A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward. Intensive Care Med 2017; 43:1485-1494. [PMID: 28852789 DOI: 10.1007/s00134-017-4910-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/11/2017] [Indexed: 01/15/2023]
Abstract
PURPOSE To provide a 360-degree description of ICU-to-ward transfers. METHODS Prospective cohort study of 451 adults transferred from a medical-surgical ICU to a hospital ward in 10 Canadian hospitals July 2014-January 2016. Transfer processes documented in the medical record. Patient (or delegate) and provider (ICU/ward physician/nurse) perspectives solicited by survey 24-72 h after transfer. RESULTS Medical records (100%) and survey responses (ICU physicians-80%, ICU nurses-80%, ward physicians-46%, ward nurses-64%, patients-74%) were available for most transfers. The median time from initiation to completion of transfer was 25 h (IQR 6-52). ICU physicians and nurses reported communicating with counterparts via telephone (78 and 75%) when transfer was requested (82 and 24%) or accepted (31 and 59%) and providing more elements of clinical information than ward physicians (mean 4.7 vs. 3.9, p < 0.001) and nurses (5.0 vs. 4.4, p < 0.001) reported receiving. Patients were more likely to report satisfaction with the transfer when they received more information (OR 1.32, 95% CI 1.18-1.48), had their questions addressed (OR 3.96, 95% CI 1.33-11.84), met the ward physician prior to transfer (OR 4.61, 95% CI 2.90-7.33), and were assessed by a nurse within 1 h of ward arrival (OR 4.70, 95% CI 2.29-9.66). Recommendations for improvement included having a documented care plan travel with the patient (all stakeholders), standardized face-to-face handover (physicians), avoiding transfers at shift change (nurses) and informing patients about pending transfers in advance (patients). CONCLUSIONS ICU-to-ward transfers are characterized by failures of patient flow and communication; experienced differently by patients, ICU/ward physicians and nurses, with distinct suggestions for improvement.
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