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Seo D, Heo I, Moon J, Kwon J, Huh Y, Kang B, Song S, Kim S, Jung K. Impact of a Rounding Checklist Implementation in the Trauma Intensive Care Unit on Clinical Outcomes. Healthcare (Basel) 2024; 12:871. [PMID: 38727427 PMCID: PMC11083085 DOI: 10.3390/healthcare12090871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
We aimed to evaluate the effectiveness of an intensive care unit (ICU) round checklist, FAST HUGS BID (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel regimen, Indwelling catheter removal, and De-escalation of antibiotics-abbreviated as FD hereafter), in improving clinical outcomes in patients with severe trauma. We included patients admitted to our trauma ICU from 2016 to 2020 and divided them into two groups: before (before-FD, 2016-2017) and after (after-FD, 2019-2020) implementation of the checklist. We compared patient characteristics and clinical outcomes, including ICU and hospital length of stay (LOS) and in-hospital mortality. Survival analysis was performed using Kaplan-Meier curves and multivariable logistic regression models; furthermore, multiple linear regression analysis was used to identify independent factors associated with ICU and hospital LOS. Compared with the before-FD group, the after-FD group had significantly lower in-hospital mortality and complication rates, shorter ICU and hospital LOS, and reduced duration of mechanical ventilation. Moreover, implementation of the checklist was a significant independent factor in reducing ICU and hospital LOS and in-hospital mortality. Implementation of the FD checklist is associated with decreased ICU and hospital LOS and in-hospital mortality.
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Affiliation(s)
- Dongmin Seo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Inhae Heo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Byunghee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Seoyoung Song
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Sora Kim
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
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He R, Bhat S, Varghese C, Rossaak J, Keane C, Baraza W, Wells CI. Interventions to Improve Patient Care on Surgical Ward Rounds: A Systematic Review. World J Surg 2023; 47:3159-3174. [PMID: 37857927 PMCID: PMC10694108 DOI: 10.1007/s00268-023-07221-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Ward rounds are an essential component of surgical and perioperative care. However, the relative effectiveness of different interventions to improve the quality of surgical ward rounds remains uncertain. The aim of this systematic review was to evaluate the efficacy of various ward round interventions among surgical patients. METHODS A systematic literature search of the MEDLINE (OVID), EMBASE (OVID), Scopus, Cumulative Index of Nursing and Allied Health (CINAHL), and PsycInfo databases was performed on 7 October 2022 in accordance with PRISMA guidelines. All studies investigating surgical ward round quality improvement strategies with measurable outcomes were included. Data were analysed via narrative synthesis based on commonly reported themes. RESULTS A total of 28 studies were included. Most were cohort studies (n = 25), followed by randomised controlled trials (n = 3). Checklists/proformas were utilised most commonly (n = 22), followed by technological (n = 3), personnel (n = 2), and well-being (n = 1) quality improvement strategies. The majority of checklist interventions (n = 21, 95%) showed significant improvements in documentation compliance, staff understanding, or patient satisfaction. Other less frequently reported ward round interventions demonstrated improvements in communication, patient safety, and reductions in patient stress levels. CONCLUSIONS Use of checklists, technology, personnel, and well-being improvement strategies have been associated with improvements in ward round documentation, communication, as well as staff and patient satisfaction. Future studies should investigate the ease of implementation and long-term durability of these interventions, in addition to their impact on clinically relevant outcomes such as patient morbidity and mortality.
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Affiliation(s)
- Reuben He
- Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, The University of Auckland, Private Bag 92019, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora MidCentral, Palmerston North, New Zealand
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Jeremy Rossaak
- Department of General Surgery, Tauranga Hospital, Te Whatu Ora Bay of Plenty, Tauranga, New Zealand
| | - Celia Keane
- Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Wal Baraza
- Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, The University of Auckland, Private Bag 92019, Auckland, New Zealand
- Department of General Surgery, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, The University of Auckland, Private Bag 92019, Auckland, New Zealand.
- Department of General Surgery, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand.
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O’Leary P, Domeracki A, Raymond J, Kozhumam A, Macha V, Sakita F, Krym V, Riccardo Nickenig Vissoci J, Staton C. A feasibility assessment of a traumatic brain injury predictive modelling tool at Kilimanjaro Christian Medical Center and Duke University Hospital. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002154. [PMID: 38016001 PMCID: PMC10684081 DOI: 10.1371/journal.pgph.0002154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/18/2023] [Indexed: 11/30/2023]
Abstract
Traumatic brain injury (TBI) is the most common cause of death and disability globally. TBI, which disproportionately affects low middle-income countries (LMIC), uses significant amounts of health system resources in costly care and management. Innovative solutions are required to address this high burden of TBI. One possible solution is prognostic models which enhance diagnostic ability of physicians, thereby helping to tailor treatments more effectively. This study aims to evaluate the feasibility of a TBI prognostic model developed in Tanzania for use by Kilimanjaro Christian Medical Center (KCMC) healthcare providers and Duke-affiliated healthcare providers using human centered design methodology. Duke participants were included to gain insight from a different context with more established practices to inform the TBI tool implementation strategy at KCMC. To evaluate the feasibility of integrating the TBI tool into potential workflows, co-design interviews were conducted with emergency physicians and nursing staff at KCMC and Duke. Qualitatively, the TBI tool was assessed using human centered design (HCD) techniques. Our research design methods were created using the Consolidated Framework for Implementation Research which considers overarching characteristics of successful implementation to contribute to theory development and verification of implementation strategies across multiple contexts. Our knowledge translation method was guided using the knowledge-to-action framework. Of the 21 participants interviewed, 12 were associated with Duke Hospital, and 9 from Kilimanjaro Christian Medical Centre. Emerging from the data were 6 themes that impacted the implementation of the TBI tool: access, barriers, facilitators, use of the TBI tool, outer setting, and inner setting. To our knowledge, this is the first study to investigate the pre-implementation of a sub-Saharan Africa (SSA) data- based TBI prediction tool using human centered design methodology. Findings of this study will aid in determining under what conditions a TBI prognostic model intervention will work at KCMC.
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Affiliation(s)
- Paige O’Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Alexis Domeracki
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Arthi Kozhumam
- Northwestern University Feinburg School of Medicine, Chicago, Illinois, United States of America
| | | | | | - Valerie Krym
- Department of Emergency Medicine, University of Toronto Medical School, Toronto, Ontario, Canada
| | - Joao Riccardo Nickenig Vissoci
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Catherine Staton
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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Oral care to reduce costs and increase clinical effectiveness in preventing nosocomial pneumonia: a systematic review. J Evid Based Dent Pract 2023; 23:101834. [DOI: 10.1016/j.jebdp.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 12/27/2022] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
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Rose L, Istanboulian L, Amaral ACKB, Burry L, Cox CE, Cuthbertson BH, Iwashyna TJ, Dale CM, Fraser I. Co-designed and consensus based development of a quality improvement checklist of patient and family-centered actionable processes of care for adults with persistent critical illness. J Crit Care 2022; 72:154153. [PMID: 36174432 DOI: 10.1016/j.jcrc.2022.154153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Few quality improvement tools specific to patients with persistent or chronic critical illness exist to aid delivery of high-quality care. Using experience-based co-design methods, we sought consensus from key stakeholders on the most important actionable processes of care for inclusion in a quality improvement checklist. METHODS Item generation methods: systematic review, semi-structured interviews (ICU survivors and family) members, touchpoint video creation, and semi-structured interviews (ICU clinicians). Consensus methods: modified online Delphi and a virtual meeting using nominal group technique methods. RESULTS We enrolled 138 ICU interprofessional team, patients, and family members. We obtained consensus on a quality improvement checklist comprising 11 core domains: patient and family involvement in decision-making; patient communication; physical comfort and complication prevention; promoting self-care and normalcy; ventilator weaning; physical therapy; swallowing; pharmacotherapy; psychological issues; delirium; and appropriate referrals. An additional 27 actionable processes are contained within 6 core domains that provide more specific direction on the actionable process to be targeted. CONCLUSIONS Using a highly collaborative and methodologically rigorous process, we generated a quality improvement checklist of actionable processes to improve patient and family-centred care considered important by key stakeholders. Future research is needed to understand optimal implementation strategies and impact on outcomes and experience.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.
| | - Laura Istanboulian
- Provincial Centre of Weaning Excellence, Michael Garron Hospital, Toronto, Toronto East Health Network, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | | | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada; University Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Theodore J Iwashyna
- University of Michigan, Ann Arbor, VA Health System, United States of America
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Ian Fraser
- Provincial Centre of Weaning Excellence, Michael Garron Hospital, Toronto East Health Network, Toronto, Canada
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Nunamaker EA, Reynolds PS. 'Invisible actors'-How poor methodology reporting compromises mouse models of oncology: A cross-sectional survey. PLoS One 2022; 17:e0274738. [PMID: 36264974 PMCID: PMC9584398 DOI: 10.1371/journal.pone.0274738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/28/2022] [Indexed: 11/05/2022] Open
Abstract
The laboratory mouse is a key player in preclinical oncology research. However, emphasis of techniques reporting at the expense of critical animal-related detail compromises research integrity, animal welfare, and, ultimately, the translation potential of mouse-based oncology models. To evaluate current reporting practices, we performed a cross-sectional survey of 400 preclinical oncology studies using mouse solid-tumour models. Articles published in 2020 were selected from 20 journals that specifically endorsed the ARRIVE (Animal Research: Reporting of In Vivo Experiments) preclinical reporting guidelines. We assessed reporting compliance for 22 items in five domains: ethical oversight assurance, animal signalment, husbandry, welfare, and euthanasia. Data were analysed using hierarchical generalised random-intercept models, clustered on journal. Overall, reporting of animal-related items was poor. Median compliance over all categories was 23%. There was little or no association between extent of reporting compliance and journal or journal impact factor. Age, sex, and source were reported most frequently, but verifiable strain information was reported for <10% of studies. Animal husbandry, housing environment, and welfare items were reported by <5% of studies. Fewer than one in four studies reported analgesia use, humane endpoints, or an identifiable method of euthanasia. Of concern was the poor documentation of ethical oversight information. Fewer than one in four provided verifiable approval information, and almost one in ten reported no information, or information that was demonstrably false. Mice are the "invisible actors" in preclinical oncology research. In spite of widespread endorsement of reporting guidelines, adherence to reporting guidelines on the part of authors is poor and journals fail to enforce guideline reporting standards. In particular, the inadequate reporting of key animal-related items severely restricts the utility and translation potential of mouse models, and results in research waste. Both investigators and journals have the ethical responsibility to ensure animals are not wasted in uninformative research.
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Affiliation(s)
- Elizabeth A. Nunamaker
- Animal Care Services, University of Florida, Gainesville, Florida, United States of America
| | - Penny S. Reynolds
- Department of Anesthesiology, Statistics in Anesthesiology Research (STAR) Core, College of Medicine, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
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Mitbander UB, Geer MJ, Taxbro K, Horowitz JK, Zhang Q, O'Malley ME, Ramnath N, Chopra V. Patterns of use and outcomes of peripherally inserted central catheters in hospitalized patients with solid tumors: A multicenter study. Cancer 2022; 128:3681-3690. [PMID: 35943390 DOI: 10.1002/cncr.34410] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND The risk of peripherally inserted central catheter (PICC)-related complications in patients hospitalized with solid tumors remains unclear. Existing studies are limited by single-center, outpatient designs and include heterogenous patients. METHODS A retrospective cohort study was designed and included adult patients with solid organ cancers who were admitted to a general medicine ward or intensive care unit and received a PICC. Data were collected from November 2013 to December 2019 at 50 Michigan hospitals. Major complications were defined as central line-associated bloodstream infection, deep vein thrombosis, pulmonary embolism, and catheter occlusion. Hospital variation in PICC use and outcomes was examined. RESULTS Data included 3235 hospitalized patients with solid tumors who had PICCs placed for 51,047 catheter days. Most catheters were double-lumen devices (57.0%). Notably, 17.5% of patients had another central venous catheter at the time of PICC insertion. The most common indications for PICC use were antibiotics (34.5%) and difficult access or blood draws (21.6%); chemotherapy was the primary indication in only 15.7% of patients. A major PICC-related complication occurred in 491 patients (15.2%); catheter occlusion was the most prevalent complication (n = 322; 10.0%) followed by deep vein thrombosis (n = 116; 3.6%), central line-associated bloodstream infection (n = 82; 2.5%), and pulmonary embolism (n = 20; 0.6%). Significant variation in indications for PICC use, device characteristics, and frequency of major complications across hospitals was observed (p < .001). CONCLUSIONS PICCs were associated with significant complications in hospitalized patients who had solid malignancies and were often used for reasons other than chemotherapy. Policies and guidance for the appropriate use of PICCs in oncologic patients appear necessary. LAY SUMMARY Peripherally inserted central catheters (PICCs) are devices placed in peripheral veins to deliver medication to large veins near the heart. PICCs are used frequently in oncology. The objective of this report was to describe PICC-associated complications in hospitalized patients with solid tumors. This study was performed across 50 Michigan hospitals and included 3235 patients with solid tumor cancers and who had a PICC. Overall, 15.2% of patients experienced a complication, including central line-associated bloodstream infections, deep vein thrombosis, pulmonary embolism, or catheter occlusion. Complication rates varied across hospitals. PICCs are associated with substantial complications in hospitalized patients with solid tumors.
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Affiliation(s)
- Urvashi B Mitbander
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Marcus J Geer
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Knut Taxbro
- Department of Anesthesia and Intensive Care Medicine, Ryhov County Hospital, Jonkoping, Sweden.,Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden
| | - Jennifer K Horowitz
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Qisu Zhang
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Megan E O'Malley
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Nithya Ramnath
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA.,Medical Oncology, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Department of Medicine, University of Colorado, Denver, Aurora, Colorado, USA
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Allum L, Apps C, Pattison N, Connolly B, Rose L. Informing the standardising of care for prolonged stay patients in the ICU: A scoping review of quality improvement tools. Intensive Crit Care Nurs 2022; 73:103302. [PMID: 35931596 DOI: 10.1016/j.iccn.2022.103302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/04/2022] [Accepted: 07/15/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To inform design of quality improvement (QI) tools specific to patients with prolonged intensive care unit (ICU) stay, we determined characteristics (format/content), development, implementation, and outcomes of published multi-component QI tools used in ICU irrespective of length of stay. RESEARCH METHODOLOGY Scoping review searching electronic databases, trial registries and grey literature (January 2000 to January 2022). RESULTS We screened 58,378 citations, identifying 96 studies. All tools were designed for use commencing at ICU admission except 3 tools implemented at 3, 5 or 14 days. We identified 32 studies of locally developed checklists, 28 goal setting/structured communication templates, 23 care bundles, and 9 studies of mixed format tools. Most (43 %) tools were designed for use during rounds, fewer tools were designed for use throughout the ICU day (27 %) or stay (9 %). Most studies (55 %) reported process objectives i.e., improving communication, care standardisation, or rounding efficiency. Most common clinical processes QI tools were used to standardise were sedation (62, 65 %), ventilation and weaning (55, 57 %), and analgesia management (58, 60 %). 44 studies reported the effect of the tool on patient outcomes. Of these, only two identified a negative effect - increased ICU length of stay and increased ICU days with pain and delirium. CONCLUSION Although we identified numerous QI tools for use in ICU settings, few were designed to specifically address actionable processes of care relevant to the unique needs of prolonged ICU stay patients. Tools that address these needs are urgently required. SYSTEMATIC REVIEW REGISTRATION The review protocol is registered on the Open Science Framework, https://osf.io/, DOI 10.17605/OSF.IO/Z8MRE.
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Affiliation(s)
- Laura Allum
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, SE1 8WA London, UK; Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH London, UK.
| | - Chloe Apps
- Critical Care Research Group and Physiotherapy Department, St. Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Rd, London SE1 7EH, UK.
| | - Natalie Pattison
- University of Hertfordshire, College Lane, Hatfield AL109AB, UK; East & North Herts NHS Trust, Coreys Mill Lane, Stevenage SG14AB, UK.
| | - Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH London, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; Centre for Human and Applied Physiological Sciences, King's College London, UK; Department of Physiotherapy, The University of Melbourne, Melbourne, Australia.
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, SE1 8WA London, UK; Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH London, UK.
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dos Santos Alves DF, da Silva SO, Ullman A, Maia FDOM. Effectiveness of checklists in multidisciplinary rounds for improving patient safety in the pediatric intensive care unit: a systematic review protocol. JBI Evid Synth 2022; 20:1835-1841. [DOI: 10.11124/jbies-21-00180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Role of Palliative Care. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00043-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Intensive care unit rounding checklists to reduce catheter-associated urinary tract infections. Infect Control Hosp Epidemiol 2021; 41:680-683. [PMID: 32127059 DOI: 10.1017/ice.2020.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs). DESIGN Retrospective before-and-after study that took place between March 2013 and February 2017. SETTING An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU. PATIENTS Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI. INTERVENTION Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods. RESULTS There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532). CONCLUSIONS Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.
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Checklist for Early Recognition and Treatment of Acute Illness and Injury: An Exploratory Multicenter International Quality-Improvement Study in the ICUs With Variable Resources. Crit Care Med 2021; 49:e598-e612. [PMID: 33729718 PMCID: PMC8132910 DOI: 10.1097/ccm.0000000000004937] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: To determine whether the “Checklist for Early Recognition and Treatment of Acute Illness and Injury” decision support tool during ICU admission and rounding is associated with improvements in nonadherence to evidence-based daily care processes and outcomes in variably resourced ICUs. DESIGN, SETTINGS, PATIENTS: This before-after study was performed in 34 ICUs (15 countries) from 2013 to 2017. Data were collected for 3 months before and 6 months after Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation. INTERVENTIONS: Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation using remote simulation training. MEASUREMENTS AND MAIN RESULTS: The coprimary outcomes, modified from the original protocol before data analysis, were nonadherence to 10 basic care processes and ICU and hospital length of stay. There were 1,447 patients in the preimplementation phase and 2,809 patients in the postimplementation phase. After adjusting for center effect, Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation was associated with reduced nonadherence to care processes (adjusted incidence rate ratio [95% CI]): deep vein thrombosis prophylaxis (0.74 [0.68–0.81), peptic ulcer prophylaxis (0.46 [0.38–0.57]), spontaneous breathing trial (0.81 [0.76–0.86]), family conferences (0.86 [0.81–0.92]), and daily assessment for the need of central venous catheters (0.85 [0.81–0.90]), urinary catheters (0.84 [0.80–0.88]), antimicrobials (0.66 [0.62–0.71]), and sedation (0.62 [0.57–0.67]). Analyses adjusted for baseline characteristics showed associations of Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation with decreased ICU length of stay (adjusted ratio of geometric means [95% CI]) 0.86 [0.80–0.92]), hospital length of stay (0.92 [0.85–0.97]), and hospital mortality (adjusted odds ratio [95% CI], 0.81 (0.69–0.95). CONCLUSIONS: A quality-improvement intervention with remote simulation training to implement a decision support tool was associated with decreased nonadherence to daily care processes, shorter length of stay, and decreased mortality.
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Singh-Franco D, Mastropietro DR, Metzner M, Dressler MD, Fares A, Johnson M, De La Rosa D, Wolowich WR. Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis. PLoS One 2020; 15:e0243134. [PMID: 33270710 PMCID: PMC7714117 DOI: 10.1371/journal.pone.0243134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Objective Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST). Methods To identify studies, the following databases were systematically searched on October 14th, 2018 and repeated on September 12th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review. Results Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I2 = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I2 = 36%). Conclusion This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
- * E-mail:
| | - David R. Mastropietro
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Miriam Metzner
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Michael D. Dressler
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Amneh Fares
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Melinda Johnson
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Daisy De La Rosa
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - William R. Wolowich
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
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McNett M, O'Mathúna D, Tucker S, Roberts H, Mion LC, Balas MC. A Scoping Review of Implementation Science in Adult Critical Care Settings. Crit Care Explor 2020; 2:e0301. [PMID: 33354675 PMCID: PMC7746210 DOI: 10.1097/cce.0000000000000301] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation. DATA SOURCES A librarian-assisted search was performed using three electronic databases. STUDY SELECTION Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included. DATA EXTRACTION Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. DATA SYNTHESIS Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes. CONCLUSIONS The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.
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Affiliation(s)
- Molly McNett
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Dónal O'Mathúna
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Sharon Tucker
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Haley Roberts
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
| | - Michele C Balas
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
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15
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Chapman LB, Kopp KE, Petty MG, Hartwig JLA, Pendleton KM, Langer K, Meiers SJ. Benefits of collaborative patient care rounds in the intensive care unit. Intensive Crit Care Nurs 2020; 63:102974. [PMID: 33262010 DOI: 10.1016/j.iccn.2020.102974] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improving care of critically ill patients requires using an interprofessional care model and care standardisation. OBJECTIVES Determine whether collaborative patient care rounds in the intensive care unit increases practice consistency with respect to common considerations such as delirium prevention, device use, and indicated prophylaxis, among others. Secondary objective to assess whether collaborative interprofessional format improved nursing perceptions of collaboration. METHODS Single centre, pre- and post- intervention design. collaborative patient care rounding format implemented in three intensive care units in an academic tertiary care centre. format consisted of scripted nursing presentation, provider checklist of additional practice considerations, and daily priority goals documentation. measurements included nursing participation, consideration of selected practice items, daily goal verbalisation, and nursing perception of collaboration. RESULTS Pre- and post-intervention measurements indicate gains in consideration of eight of thirteen bundle items (p < 0.05), with the greatest gains seen in nurse-presented items. Increases were observed in verbalisation of daily goals (59.8% versus 89.1%, p < 0.0001), nurse participation (83.9% versus 91.8%, p = 0.056), and nurse collaboration ratings (p < 0.0001). CONCLUSION This study describes implementation of collaborative patient care rounds with corresponding increases in consideration of selected practice items, verbalisation of daily goals, and perceptions of collaboration.
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Affiliation(s)
- Leah B Chapman
- Department of Graduate Nursing, Winona State University, Rochester, MN, United States; University of Minnesota Medical Center, Minneapolis, MN, United States.
| | - Kathleen E Kopp
- Department of Graduate Nursing, Winona State University, Rochester, MN, United States; University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Michael G Petty
- University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Jodi L A Hartwig
- University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Kathryn M Pendleton
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Kimberly Langer
- Department of Graduate Nursing, Winona State University, Rochester, MN, United States
| | - Sonia J Meiers
- Department of Graduate Nursing, Winona State University, Rochester, MN, United States
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De Bie AJR, Mestrom E, Compagner W, Nan S, van Genugten L, Dellimore K, Eerden J, van Leeuwen S, van de Pol H, Schuling F, Lu X, Bindels AJGH, Bouwman ARA, Korsten EHHM. Intelligent checklists improve checklist compliance in the intensive care unit: a prospective before-and-after mixed-method study. Br J Anaesth 2020; 126:404-414. [PMID: 33213832 DOI: 10.1016/j.bja.2020.09.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We examined whether a context and process-sensitive 'intelligent' checklist increases compliance with best practice compared with a paper checklist during intensive care ward rounds. METHODS We conducted a single-centre prospective before-and-after mixed-method trial in a 35 bed medical and surgical ICU. Daily ICU ward rounds were observed during two periods of 8 weeks. We compared paper checklists (control) with a dynamic (digital) clinical checklist (DCC, intervention). The primary outcome was compliance with best clinical practice, measured as the percentages of checked items and unchecked critical items. Secondary outcomes included ICU stay and the usability of digital checklists. Data are presented as median (interquartile range). RESULTS Clinical characteristics and severity of critical illness were similar during both control and intervention periods of study. A total of 36 clinicians visited 197 patients during 352 ward rounds using the paper checklist, compared with 211 patients during 366 ward rounds using the DCC. Per ICU round, a median of 100% of items (94.4-100.0) were completed by DCC, compared with 75.1% (66.7-86.4) by paper checklist (P=0.03). No critical items remained unchecked by the DCC, compared with 15.4% (8.3-27.3) by the paper checklist (P=0.01). The DCC was associated with reduced ICU stay (1 day [1-3]), compared with the paper checklist (2 days [1-4]; P=0.05). Usability of the DCC was judged by clinicians to require further improvement. CONCLUSIONS A digital checklist improved compliance with best clinical practice, compared with a paper checklist, during ward rounds on a mixed ICU. CLINICAL TRIAL REGISTRATION NCT03599856.
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Affiliation(s)
- Ashley J R De Bie
- Department of Internal Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; Industrial Engineering and Innovation Sciences, Eindhoven University of Technology, Eindhoven, The Netherlands; Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
| | - Eveline Mestrom
- Department of Internal Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; Industrial Engineering and Innovation Sciences, Eindhoven University of Technology, Eindhoven, The Netherlands; Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Wilma Compagner
- Healthcare Intelligence, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Shan Nan
- Industrial Engineering and Innovation Sciences, Eindhoven University of Technology, Eindhoven, The Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands; College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
| | - Lenneke van Genugten
- Department of Brain, Behaviour and Cognition, Philips Research, Eindhoven, The Netherlands
| | - Kiran Dellimore
- Department of Patient Care and Measurements, Philips Research, Eindhoven, The Netherlands
| | - Jacco Eerden
- Department of Philips Design, Eindhoven, The Netherlands
| | | | - Harald van de Pol
- Healthcare Intelligence, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Xudong Lu
- College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
| | | | - Arthur R A Bouwman
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands; Department of Anaesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Erik H H M Korsten
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; Healthcare Intelligence, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
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Abstract
OBJECTIVES To eliminate catheter-associated urinary tract infections in a pediatric cardiac ICU. DESIGN Quality improvement methodology. SETTING Twenty-five bed cardiac ICU in a quaternary freestanding children's hospital. PATIENTS All patients with an indwelling urinary catheter admitted to the cardiac ICU. INTERVENTIONS Catheter-associated urinary tract infection was defined according to National Healthcare Safety Network criteria. Failure modes and effects analysis and Pareto charts were used to determine etiology of process failures. We implemented a team-based multi-interventional approach in 2012 using the Model for Improvement, which included as follows: 1) establish indications for inserting and/or maintaining bladder catheterization, 2) standardization of maintenance care for the indwelling urinary catheters, 3) protocol for management of the leaking urinary catheters, 4) incorporation of urinary catheter days and prompts for removal in daily rounds, and 5) review of all cases of prolonged indwelling urinary catheter use (> 3 d). Process control charts were used to evaluate change. MEASUREMENTS AND MAIN RESULTS From 2011 to 2018, we showed an early and sustained improvement in catheter-associated urinary tract infection prevention standards compliance from 44% to 96% (52% improvement). These interventions showed a reduction and then elimination of catheter-associated urinary tract infections from January 2012 to the present day, despite fluctuations in total indwelling urinary catheter days. CONCLUSIONS Utilization of quality improvement methodology allowed us to identify components of care that contributed to catheter-associated urinary tract infections. After addressing these issues, we noted a substantial reduction and then elimination of catheter-associated urinary tract infections in our pediatric cardiac ICU. Widely disseminating these interventions across multiple pediatric hospitals to determine the ability to achieve similar results are important next steps.
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Vasudevan L, Schroeder K, Raveendran Y, Goel K, Makarushka C, Masalu N, Zullig LL. Using digital health to facilitate compliance with standardized pediatric cancer treatment guidelines in Tanzania: protocol for an early-stage effectiveness-implementation hybrid study. BMC Cancer 2020; 20:254. [PMID: 32223740 PMCID: PMC7104518 DOI: 10.1186/s12885-020-6611-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background In high-income countries (HICs), increased rates of survival among pediatric cancer patients are achieved through the use of protocol-driven treatment. Compared to HICs, differences in infrastructure, supportive care, and human resources, make compliance with protocol-driven treatment challenging in low- and middle-income countries (LMICs). For successful implementation of protocol-driven treatment, treatment protocols must be resource-adapted for the LMIC context, and additional supportive tools must be developed to promote protocol compliance. In Tanzania, an LMIC where resource-adapted treatment protocols are available, digital health applications could promote protocol compliance through incorporation of systematic decision support algorithms, reminders and alerts related to patient visits, and up-to-date data for care coordination. However, evidence on the use of digital health applications in improving compliance with protocol-driven treatment for pediatric cancer is limited. This study protocol describes the development and evaluation of a digital health application, called mNavigator, to facilitate compliance with protocol-driven treatment for pediatric cancer in Tanzania. Methods mNavigator is a digital case management system that incorporates nationally-approved and resource-adapted treatment protocols for two pediatric cancers in Tanzania, Burkitt lymphoma and retinoblastoma. mNavigator is developed from an open-source digital health platform, called CommCare, and guided by the Consolidated Framework for Implementation Research. From July 2019–July 2020 at Bugando Medical Centre in Mwanza, Tanzania, all new pediatric cancer patients will be registered and managed using mNavigator as the new standard of care for patient intake and outcome assessment. Pediatric cancer patients with a clinical diagnosis of Burkitt lymphoma or retinoblastoma will be approached for participation in the study evaluating mNavigator. mNavigator users will document pre-treatment and treatment details for study participants using digital forms and checklists that facilitate compliance with protocol-driven treatment. Compliance with treatment protocols using mNavigator will be compared to historical compliance rates as the primary outcome. Throughout the implementation period, we will document factors that facilitate or inhibit mNavigator implementation. Discussion Study findings will inform implementation and scale up of mNavigator in tertiary pediatric cancer facilities in Tanzania, with the goal of facilitating protocol-driven treatment. Trial registration The study protocol was registered in ClinicalTrials.gov (NCT03677128) on September 19, 2018.
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Affiliation(s)
- Lavanya Vasudevan
- Department of Family Medicine and Community Health, Duke School of Medicine, 2200 W. Main Street, Durham, NC, 27710, USA. .,Duke Global Health Institute, 310 Trent Drive, Durham, NC, 27710, USA.
| | - Kristin Schroeder
- Duke Global Health Institute, 310 Trent Drive, Durham, NC, 27710, USA.,Department of Pediatrics, Division of Hematology/Oncology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27710, USA.,Bugando Medical Centre, Wurtzburg Road, Mwanza, Tanzania
| | | | - Kunal Goel
- Duke School of Medicine, 8 Searle Center Drive, Durham, NC, 27710, USA
| | - Christina Makarushka
- Department of Family Medicine and Community Health, Duke School of Medicine, 2200 W. Main Street, Durham, NC, 27710, USA
| | - Nestory Masalu
- Bugando Medical Centre, Wurtzburg Road, Mwanza, Tanzania
| | - Leah L Zullig
- Department of Population Health Sciences, 215 Morris St, Durham, NC, 27701, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton St, Durham, NC, 27705, USA
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Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients. Pediatr Qual Saf 2020; 5:e253. [PMID: 32190798 PMCID: PMC7056290 DOI: 10.1097/pq9.0000000000000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 12/25/2019] [Indexed: 11/26/2022] Open
Abstract
The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line-associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit. Methods All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts. Results We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013. Conclusions Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.
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Ogasawara O, Kojima T, Miyazu M, Sobue K. Impact of the stress ulcer prophylactic protocol on reducing the unnecessary administration of stress ulcer medications and gastrointestinal bleeding: a single-center, retrospective pre-post study. J Intensive Care 2020; 8:10. [PMID: 31988751 PMCID: PMC6966877 DOI: 10.1186/s40560-020-0427-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022] Open
Abstract
Background Clinically significant gastrointestinal bleeding from stress ulcers increases patient mortality in intensive care, and histamine type 2 receptor blockers and proton pump inhibitors as stress ulcer prophylaxes were reported to decrease the incidence of that. Although medical checklists are widely used to maintain high compliance with medications and interventions to improve patient outcome in the intensive care field, the efficacy of medical checklists regarding the incidence of gastrointestinal bleeding and the reduction of unnecessary administration of stress ulcer prophylaxis medications has not been sufficiently explored to date. This study aimed to investigate the incidence of gastrointestinal bleeding and the rate of administering stress ulcer prophylaxis medication before and after setting administration criteria for stress ulcer prophylaxis and introducing a medical checklist for critically ill adults. Methods This was a retrospective pre-post study at a single-center, tertiary adult and pediatric mixed ICU. Adult patients (≥ 18 years) who were admitted to the ICU for reasons other than gastrectomy, esophagectomy, pancreatoduodenectomy, and gastrointestinal bleeding were analyzed. A medical checklist and stress ulcer prophylaxis criteria were introduced on December 22, 2014, and the patients were classified into the preintervention group (from September to December 21, 2014) and the postintervention group (from December 22, 2014, to April 2015). The primary outcome was the incidence of upper gastrointestinal bleeding, and the secondary outcome was the proportion administered stress ulcer prophylaxis medications. Results One hundred adult patients were analyzed. The incidence of upper gastrointestinal bleeding in the pre- and postintervention groups was both 4.0% [95% confidence interval, 0.5–13.7%]. The proportion administered stress ulcer prophylaxis medications decreased from 100 to 38% between the pre- and post-intervention groups. Conclusions After the checklist and the criteria were introduced, the administration of stress ulcer prophylaxis medications decreased without an increase in upper gastrointestinal bleeding in critically ill adults. Prospective studies are necessary to evaluate the causal relationship between the introduction of them and gastrointestinal adverse events in critically ill adults.
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Affiliation(s)
- Osamu Ogasawara
- 1Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601 Japan
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, 7-426, Morioka-cho, Obu, Aichi 474-0031 Japan
| | - Mitsunori Miyazu
- Department of Anesthesiology, Aichi Children's Health and Medical Center, 7-426, Morioka-cho, Obu, Aichi 474-0031 Japan
| | - Kazuya Sobue
- 1Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601 Japan
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Lemkin DL, Stryckman B, Klein JE, Custer JW, Bame W, Maranda L, Wood KE, Paulson C, Dezman ZDW. Integrating a safety smart list into the electronic health record decreases intensive care unit length of stay and cost. J Crit Care 2019; 57:246-252. [PMID: 31911086 DOI: 10.1016/j.jcrc.2019.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/28/2019] [Accepted: 09/16/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To measure how an integrated smartlist developed for critically ill patients would change intensive care units (ICUs) length of stay (LOS), mortality, and charges. MATERIALS AND METHODS Propensity-score analysis of adult patients admitted to one of 14 surgical and medical ICUs between June 2017 and May 2018. The smart list aimed to certain preventative measures for all critical patients (e.g., removing unneeded catheters, starting thromboembolic prophylaxis, etc.) and was integrated into the electronic health record workflows at the hospitals under study. RESULTS During the study period, 11,979 patients were treated in the 14 participating ICUs by 518 unique providers. Patients who had the smart list used during ≥60% of their ICU stay (N = 432 patients, 3.6%) were significantly more likely to have a shorter ICU LOS (HR = 1.20, 95% CI:1.0 to 1.4, p = 0.015) with an average decrease of -$1218 (95% CI: -$1830 to -$607, P < 0.001) in the amount charged per day. The intervention cohort had fewer average ventilator days (3.05 vent days, SD = 2.55) compared to propensity score matched controls (3.99, SD = 4.68, p = 0.015), but no changes in mortality (16.7% vs 16.0%, p = 0.78). CONCLUSIONS An integrated smart list shortened LOS and lowered charges in a diverse cohort of critically ill patients.
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Affiliation(s)
- Daniel L Lemkin
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Benoit Stryckman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joel E Klein
- University of Maryland Medical System, Baltimore, MD, USA
| | - Jason W Custer
- Division of Pediatric Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William Bame
- Data & Analytics, University of Maryland Medical System Baltimore, MD, USA
| | - Louise Maranda
- Department of Quantitative Sciences, University of Massachusetts, Worcester, MA, USA
| | - Kenneth E Wood
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Courtney Paulson
- Department of Decision, Operations, and Information Technologies, University of Maryland Robert H. Smith School of Business, College Park, MD, USA
| | - Zachary D W Dezman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
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Sirvent JM, Cordon C, Cuenca S, Fuster C, Lorencio C, Ortiz P. Application, verification and correction from an elaborate checklist with some of the recommendations («do and do not do») of the SEMICYUC working groups. Med Intensiva 2019; 45:88-95. [PMID: 31477342 DOI: 10.1016/j.medin.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/08/2019] [Accepted: 07/15/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Based on some of the recommendations of the SEMICYUC working groups, we developed a checklist and applied it in 2 periods, analyzing their behavior as a tool for improving safety. DESIGN A comparative pre- and post-intervention longitudinal study was carried out. SETTING The Intensive Care Unit (ICU) of a 400-bed university hospital. PATIENTS Random cases series in 2 periods separated by 6 months. INTERVENTIONS We developed a checklist with 24 selected indicators that were randomly applied to 50 patients. Verification was conducted by a professional not related to care (prompter). We analyzed the results and compliance index and carried out corrective measures with training. With 6 months of preparation, we again applied the random checklist to 50 patients (post-intervention period) and compared the compliance indexes between the two timepoints. RESULTS There were no differences in demographic characteristics or evolution between the periods. The compliance index at baseline was 0.86±0.12 versus 0.91±0.52 in the post-intervention period (P=.023). An acceptable compliance index was obtained with the 24 indicators, though at baseline the compliance index was<0.85 for 5 recommendations. These detected non-compliances were worked upon through training in the second phase of the study. The post-intervention checklist evidenced improvement in compliance with the recommendations. CONCLUSIONS The checklist used to assess compliance with a selection of recommendations of the SEMICYUC applied and moderated by a prompter was seen to be a useful instrument allowing us to identify points for improvement in the management of Intensive Care Unit patients, increasing the quality and safety of care.
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Affiliation(s)
- J-M Sirvent
- Servicio de Medicina Intensiva (UCI), Hospital Universitario de Girona Doctor Josep Trueta, Girona, España.
| | - C Cordon
- Servicio de Medicina Intensiva (UCI), Hospital Universitario de Girona Doctor Josep Trueta, Girona, España
| | - S Cuenca
- Servicio de Medicina Intensiva (UCI), Hospital Universitario de Girona Doctor Josep Trueta, Girona, España
| | - C Fuster
- Servicio de Medicina Intensiva (UCI), Hospital Universitario de Girona Doctor Josep Trueta, Girona, España
| | - C Lorencio
- Servicio de Medicina Intensiva (UCI), Hospital Universitario de Girona Doctor Josep Trueta, Girona, España
| | - P Ortiz
- Servicio de Medicina Intensiva (UCI), Hospital Universitario de Girona Doctor Josep Trueta, Girona, España
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van Maarseveen OEC, Ham WHW, van de Ven NLM, Saris TFF, Leenen LPH. Effects of the application of a checklist during trauma resuscitations on ATLS adherence, team performance, and patient-related outcomes: a systematic review. Eur J Trauma Emerg Surg 2019; 46:65-72. [PMID: 31392359 PMCID: PMC7026213 DOI: 10.1007/s00068-019-01181-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 07/01/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE In this systematic literature review, the effects of the application of a checklist during in hospital resuscitation of trauma patients on adherence to the ATLS guidelines, trauma team performance, and patient-related outcomes were integrated. METHODS A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist. The search was performed in Pubmed, Embase, CINAHL, and Cochrane inception till January 2019. Randomized controlled- or controlled before-and-after study design were included. All other forms of observational study designs, reviews, case series or case reports, animal studies, and simulation studies were excluded. The Effective Public Health Practice Project Quality Assessment Tool was applied to assess the methodological quality of the included studies. RESULTS Three of the 625 identified articles were included, which all used a before-and-after study design. Two studies showed that Advanced Trauma Life Support (ATLS)-related tasks are significantly more frequently performed when a checklist was applied during resuscitation. [14 of 30 tasks (p < 0.05), respectively, 18 of 19 tasks (p < 0.05)]. One study showed that time to task completion (- 9 s, 95% CI = - 13.8 to - 4.8 s) and workflow improved, which was analyzed as model fitness (0.90 vs 0.96; p < 0.001); conformance frequency (26.1% vs 77.6%; p < 0.001); and frequency of unique workflow traces (31.7% vs 19.1%; p = 0.005). One study showed that the incidence of pneumonia was higher in the group where a checklist was applied [adjusted odds ratio (aOR) 1.69, 95% Confidence Interval (CI 1.03-2.80)]. No difference was found for nine other assessed complications or missed injuries. Reduced mortality rates were found in the most severely injured patient group (Injury Severity score > 25, aOR 0.51, 95% CI 0.30-0.89). CONCLUSIONS The application of a checklist may improve ATLS adherence and workflow during trauma resuscitation. Current literature is insufficient to truly define the effect of the application of a checklist during trauma resuscitation on patient-related outcomes, although one study showed promising results as an improved chance of survival for the most severely injured patients was found.
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Affiliation(s)
- Oscar E C van Maarseveen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Wietske H W Ham
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Institute of Nursing Studies, University of Applied Sciences Utrecht, Heidelberglaan 7, 3584 CS, Utrecht, The Netherlands
| | - Nils L M van de Ven
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Tim F F Saris
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Prompting Rounding Teams to Address a Daily Best Practice Checklist in a Pediatric Intensive Care Unit. Jt Comm J Qual Patient Saf 2019; 45:543-551. [PMID: 31326347 DOI: 10.1016/j.jcjq.2019.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 04/29/2019] [Accepted: 05/03/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Implementation of best practices for pediatric ICU (PICU) patients is challenging. The objective of this project was to improve process of care outcomes and clinical outcomes by having a dedicated person (quality champion [QC]) prompt PICU rounding teams to address a daily best practice rounding checklist. METHODS A prospective cohort study was performed in an academic tertiary referral PICU, which implemented a daily rounding checklist, including reminders to assess central line/urinary catheter need, sedation goals, sedative/paralytic need, enteral nutrition readiness, and extubation readiness. Data were collected on patient characteristics, process of care outcomes, and clinical outcomes over three periods: before and after the checklist was implemented and after the practice of prompting for checklist use was instituted. RESULTS Over nine months, 444 patients were included. The QC was present on rounds 94 of 139 (67.6%) days. Checklist adherence (all checklist items discussed daily) improved from 75.7% to 86.6% of patients. There was a reduction in urinary catheter days across all time periods (p = 0.001), and post hoc analysis showed fewer blood draws (p = 0.049) among patients for whom the QC was present consistently during rounds. There was also a decrease in PICU length of stay after the checklist was implemented (p = 0.008), although this may be due to less severity of illness in the prompted cohort. CONCLUSION Prompting PICU rounding teams to address a daily best practice rounding checklist may improve some process of care outcomes. Further study is needed to delineate long-term effects of this initiative.
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Pelkofski EB, Baker WD, Rowlingson JC, Cantrell LA, Duska LR. Quality Initiative to Improve Compliance With Perioperative Anticoagulation. J Oncol Pract 2019; 15:e835-e842. [PMID: 31206339 DOI: 10.1200/jop.18.00748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in gynecologic oncology surgical patients. Many centers use neuraxial analgesia (NA), which affects the timing of prophylactic anticoagulation. In 2012, we determined that the rate of VTE in patients undergoing laparotomy with NA was higher than in those who received alternative pain control. In addition, compliance with preoperative anticoagulation guidelines was only 40%. We undertook a quality initiative (QI) project to increase compliance to 80% in NA cases and maintain 90% in non-NA cases. METHODS A multidisciplinary working group designed and deployed a QI intervention bundle. Compliance was defined as the receipt of a prophylactic dose of anticoagulant within 1 hour after NA or before skin incision regardless of anesthesia type. Data were abstracted from the medical record after the study period. Cases from the year before QI were used for comparison. Primary outcome was compliance and secondary outcome was the rate of VTE. RESULTS One hundred women were treated under the QI project and 182 historical cases (HCs) were used for comparison. Overall compliance improved (96% QI v 73% HC; P < .001). This difference was marked in cases with NA (95% QI v 40% HC; P < .001) and remained stable in non-NA cases (97% QI v 91% HC; P = .29). The overall rate of VTE, independent of anesthesia type, remained unchanged (2.1% HC v 0% QI; P = .3). CONCLUSION Relatively simple and inexpensive initiatives to improve routine processes within the surgical pathway are feasible and attract staff participation. Such efforts are likely to translate into greater levels of patient safety.
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Carvalho AGRD, Moraes APPD, Carvalho ACPD, Silva AAMD. Quality assessment of adult intensive care services: application of a tool adjusted to the reality of low-income countries. Rev Bras Ter Intensiva 2019; 31:138-146. [PMID: 31166557 PMCID: PMC6649218 DOI: 10.5935/0103-507x.20190031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 12/16/2018] [Indexed: 01/09/2023] Open
Abstract
Objective To assess the quality of adult intensive care units. Methods This population-based, cross-sectional, observational, analytical study
evaluated management type in Maranhão, Brazil. An assessment
instrument was applied that assigned scores to each service (maximum 124
points). The units were categorized as insufficient (< 50% of the maximum
score), typical (≥ 50% and <80% of the maximum score), or
sufficient (≥ 80% of the maximum score). Results Of the 26 intensive care units in Maranhão, 23 were evaluated; 15
(65.2%) were located in the state capital, and 14 (60.9%) were public. The
mean final score was 67.2 (54.2% of the maximum). The worst performance was
observed with regard to processes (50.9%) in the units located outside the
capital (p = 0.037) and for hospitals with 68 beds or fewer (p = 0.027). The
result of the assessment categorized services as a function of the overall
total points earned. Specifically, 8 (34.8%) services were assessed as
insufficient, 13 (56.5%) were assessed as typical, and 2 (8.7%) were
assessed as sufficient. Conclusion The majority of the intensive care units in this study were assessed as
typical. These services must be better qualified. The priorities are the
processes of the units located outside the capital and in small
hospitals.
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Patient and Family Centered Actionable Processes of Care and Performance Measures for Persistent and Chronic Critical Illness: A Systematic Review. Crit Care Explor 2019; 1:e0005. [PMID: 32166252 PMCID: PMC7063874 DOI: 10.1097/cce.0000000000000005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Supplemental Digital Content is available in the text. To identify actionable processes of care, quality indicators, or performance measures and their evidence base relevant to patients with persistent or chronic critical illness and their family members including themes relating to patient/family experience.
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Udelsman BV, Lee KC, Traeger LN, Lillemoe KD, Chang DC, Cooper Z. Clinician-to-Clinician Communication of Patient Goals of Care Within a Surgical Intensive Care Unit. J Surg Res 2019; 240:80-88. [PMID: 30909068 DOI: 10.1016/j.jss.2019.02.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/22/2019] [Accepted: 02/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little is known about the process by which inpatient teams document and convey goals of care (GOC) for critically ill surgical patients. We sought to explore clinician perspectives on the barriers and facilitators to clinician-to-clinician communication and delivery of goal-concordant patient care. METHODS Purposive and snowball sampling were used to recruit a multidisciplinary sample of clinicians who held roles in a surgical intensive care unit at a single tertiary care facility. Semistructured interviews with clinicians were conducted between September and December 2017 to assess clinician experiences with communicating and honoring patient GOC. Two independent coders performed qualitative coding in an iterative fashion using a framework approach. Inter-rater agreement was measured by kappa coefficient. RESULTS Thirty-three clinicians from multiple disciplines including surgery, anesthesiology, nursing, and social work, were interviewed. Analysis revealed that clinicians in all disciplines felt responsible for honoring patient GOC. Conflicts over patient GOC and how to honor them arose between clinicians with longitudinal patient relationships (preoperative and postoperative) and those with single-phase relationships (postoperative). Barriers to clinician-to-clinician communication and delivery of goal-concordant care included inaccessible records, lack of protocols, and difficulty in documenting complex conversations. Facilitators included recognition of a patient's unique treatment priorities and family members with a unified understanding of a patient's GOC. CONCLUSIONS Differences in the clinician-patient relationships and difficulty accessing information about patient preferences contribute to clinician conflicts and concerns with the goal concordance of patient care.
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Affiliation(s)
- Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Katherine C Lee
- Department of Surgery, University of California San Diego, San Diego, California; Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, Massachusetts
| | - Lara N Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston Massachusetts
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Decreasing failed extubations with the implementation of an extubation checklist. Am J Surg 2019; 217:1072-1075. [PMID: 30890263 DOI: 10.1016/j.amjsurg.2019.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 12/28/2018] [Accepted: 02/22/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Failed extubation has been shown to increase ICU stay, transfers to rehabilitation facilities, and mortality. The purpose of this study was to assess the differences in rates of failed extubation before and after implementation of an extubation checklist. METHODS We performed a retrospective study from January 2013-April 2017 on adult trauma patients (age 18-89) who were admitted to the ICU and required mechanical ventilation. Patients were grouped before and after implementation of an extubation checklist and compared. RESULTS A total of 993 patients were included in this study. After checklist implementation, significantly fewer patients required reintubation compared to those prior to checklist (7% vs 3%, p = 0.005). There was no difference in mortality (20% vs 21%, p = 0.54) or hospital length of stay between the two groups (16 days vs 15 days, p = 0.16). CONCLUSION Our study reveals that implementing an extubation checklist is associated with fewer failed extubations.
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Mansfield SA, Ryshen G, Dail J, Gossard M, McClead R, Aldrink JH. Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis. J Pediatr Surg 2018; 53:1578-1583. [PMID: 29291893 DOI: 10.1016/j.jpedsurg.2017.11.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/26/2017] [Accepted: 11/30/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Gastroschisis is a congenital defect of the abdominal wall leading to considerable morbidity and long hospitalizations. The purpose of this study was to use quality improvement methodology to standardize care in the management of gastroschisis that may contribute to length of stay (LOS). METHODS A gastroschisis quality improvement team established a best-practice protocol in order to decrease LOS in infants with uncomplicated gastroschisis. The specific aim was to decrease median LOS from a baseline of 34days. We used statistical process control charts including rational subgroup analysis to monitor LOS. RESULTS From December 2008 to December 2016, 119 patients with uncomplicated gastroschisis were evaluated. Retrospective data were obtained on 25 patients prior to protocol implementation. Ninety-four patients with uncomplicated gastroschisis comprised the prospective process stage. The median LOS for this retrospective cohort was 34days (IQR: 30.5-50.5), while the median LOS for the prospective cohort following implementation of the protocol decreased to 29days (IQR: 23-43). CONCLUSIONS With the use of quality improvement methodology, including standardization of care and a change in surgical approach, the median LOS for newborns with uncomplicated gastroschisis at our institution decreased from 34days to 29days. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Sara A Mansfield
- Department of General Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Gregory Ryshen
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH
| | - James Dail
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH
| | - Mary Gossard
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Richard McClead
- Department of Pediatrics, Division of Neonatology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH.
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A Checklist Manifesto: Effectiveness of Checklist Use in Hands-On Simulation Examining Competency in Contrast Reaction Management in a Randomized Controlled Study. AJR Am J Roentgenol 2018; 211:W1-W12. [PMID: 29812983 DOI: 10.2214/ajr.17.19384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this article is to assess the performance of a contrast reaction management checklist for optimal management of a contrast reaction scenario created using a high-fidelity hands-on simulation. MATERIALS AND METHODS A safety checklist was designed that presented the five adverse events that most commonly occur after administration of IV contrast medium as well as their step-by-step management. Forty-three radiology residents were randomized into two groups, a checklist group (n = 22) and a control group (n = 21), as stratified by postgraduate year. Participants took written tests involving multiple-choice questions 2 months before and immediately after participating in the high-fidelity simulation scenario, which was videotaped and independently evaluated by three graders. RESULTS Both groups had similar scores on the multiple-choice question tests taken before and after participation in the simulation (p = 0.35 and p = 0.62, respectively). In the simulation, the checklist group scored significantly higher than the control group with regard to their overall management of a severe contrast reaction (85.1% vs 64.8%; p = 0.001), including individual scores for first-line treatment of bronchospasm (97.0% vs 91.3%; p = 0.035) and use of the correct route of administration and dose of epinephrine (77.3% vs 45.2%; p = 0.021). CONCLUSION A standardized contrast reaction management checklist can reduce the number of treatment errors that occur during a simulated severe contrast reaction, particularly with regard to proper administration of epinephrine and treatment of bronchospasm. Such a checklist could be used by radiologists, technologists, and nurses to improve patient safety as a result of improved contrast reaction management and teamwork skills.
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Siegel BI, Figueroa J, Stockwell JA. Impact of a Daily PICU Rounding Checklist on Urinary Catheter Utilization and Infection. Pediatr Qual Saf 2018; 3:e078. [PMID: 30229190 PMCID: PMC6132817 DOI: 10.1097/pq9.0000000000000078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 03/27/2018] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION In critically ill children, inappropriate urinary catheter (UC) utilization is associated with increased morbidity, including catheter-associated urinary tract infections (CAUTIs). Checklists are effective for reducing medical errors, but there is little data on their impact on device utilization in pediatric critical care. In this study, we evaluated UC utilization trends and CAUTI rate after implementing a daily rounding checklist. METHODS A retrospective review of our checklist database from 2006 through 2016 was performed. The study setting was a 36-bed pediatric intensive care unit in a quaternary-care pediatric hospital. Interventions included the "Daily QI Checklist" in 2006, ongoing education regarding device necessity, and a CAUTI prevention bundle in 2013. UC utilization and duration were assessed via auto-correlated time series models and Cochran-Armitage tests for trend. Changes in CAUTI rate were assessed via Poisson regression. RESULTS UC utilization decreased from 30% of patient-days in 2006 to 18% in 2016 (P < 0.0001, Cochran-Armitage trend test), while duration of UC use (median, 2.0 days; interquartile range, 1-4) did not change over time (P = 0.18). CAUTI rate declined from 9.49/1,000 UC-days in 2009 to 1.04 in 2016 (P = 0.0047). CONCLUSIONS Implementation of the checklist coincided with a sustained 40% reduction in UC utilization. The trend may be explained by a combination of more appropriate selection of patients for catheterization and improved timeliness of UC discontinuation. We also observed an 89% decline in CAUTI rate that occurred after stabilization of UC utilization. These findings underscore the potential impact of a checklist on incorporating best practices into daily care of critically ill children.
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Affiliation(s)
- Benjamin I Siegel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Janet Figueroa
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Jana A Stockwell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
- Division of Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Ga
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Boots R. Prevention of Nosocomial Infection in the Neurosciences Intensive Care Unit: Remember the Basics. Neurocrit Care 2018; 25:167-9. [PMID: 27535771 DOI: 10.1007/s12028-016-0314-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Rob Boots
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Burns Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia.
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Nel MJ, Hardcastle TC. Preventative measures taken against hypothermia in selected Durban hospitals' emergency centres and operating theatres. Afr J Emerg Med 2017; 7:172-176. [PMID: 30456134 PMCID: PMC6234136 DOI: 10.1016/j.afjem.2017.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 04/03/2017] [Accepted: 05/05/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Hypothermia is common in emergency general surgical patients. It is known to be associated with major complications in multiple organ systems. It is also easily preventable with the use of safe and cost-effective equipment. However, by observation, it appears that this equipment is used too infrequently thus resulting in unnecessary harm to patients. Methods This descriptive, observational, cross-sectional study was conducted in two arms to evaluate both emergency centres and operating theatres in the major state hospitals in Durban. It was conducted as an audit as well as a questionnaire-based study, to ascertain the availability of equipment used to prevent hypothermia and also how appropriately the equipment was being used. Results There was good availability of equipment in both the operating theatres and the emergency centres. However it was being used very poorly, particularly in emergency centres (41% of responses deemed not beneficial to patients versus 29% from operating theatres; 39% of answers beneficial versus 54% from operating theatres). Institutions with hypothermia-prevention protocols scored significantly better than those without a protocol (59% versus 25% beneficial; p = 0.01). Conclusion In the field of hypothermia prevention, there was sufficient equipment to result in optimal patient care. However there appears to be a lack of knowledge amongst health care providers, resulting in suboptimal use of this equipment. Protocolised management may provide a solution to this problem and improve patient outcomes.
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Tainter CR, Nguyen AP, Pollock KA, O'Brien EO, Lee J, Schmidt U, Jahanasouz F, Owens RL, Meier A. The impact of a daily "medication time out" in the Intensive Care Unit. J Crit Care 2017; 43:366-369. [PMID: 28939276 DOI: 10.1016/j.jcrc.2017.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/25/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Medical errors play a large role in preventable harms within our health care system. Medications administered in the ICU can be numerous, complex and subject to daily changes. We describe a method to identify medication errors with the potential to improve patient safety. DESIGN A quality improvement intervention featuring a daily medication time out for each patient was performed during rounds. SETTING A 12-bed Cardiac Surgical ICU at a single academic institution with approximately 180 beds. INTERVENTION After each patient encounter, the current medication list for the patient was read aloud from the electronic medical record, and the team would determine if any were erroneous or missing. Medication changes were recorded and graded post-hoc according to perceived significance. RESULTS This intervention resulted in 285 medication changes in 347 patient encounters. 179 of the 347 encounters (51.6%) resulted in at least one change. Of the changes observed, 40.4% were categorized as trivial, 50.5% as minor and 9.1% were considered to have significant potential impact on patient care. The average time spent per patient for this intervention was 1.24 (SD 0.65) minutes. CONCLUSIONS A daily medication time out should be considered as an additional mechanism for patient safety in the ICU.
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Affiliation(s)
- Christopher R Tainter
- Department of Emergency Medicine and Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, CA, United States
| | - Albert P Nguyen
- Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, CA, United States
| | - Kimberly A Pollock
- Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, CA, United States
| | - Edward O O'Brien
- Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, CA, United States
| | - Jarone Lee
- Department of Emergency Medicine and Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Ulrich Schmidt
- Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, CA, United States
| | - Farivar Jahanasouz
- Department of Pharmacy, University of California, San Diego, San Diego, CA, United States
| | - Robert L Owens
- Department of Pulmonary Critical Care and Sleep Medicine, University of California, San Diego, CA, United States
| | - Angela Meier
- Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, CA, United States.
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Corwin GS, Mills PD, Shanawani H, Hemphill RR. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2017; 43:580-590. [PMID: 29056178 DOI: 10.1016/j.jcjq.2017.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 04/13/2017] [Accepted: 04/14/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND ICUs' provision of complex care for critically ill patients results in an environment with a high potential for adverse events. A study was conducted to characterize adverse events in Veterans Health Administration (VHA) ICUs that underwent root cause analysis (RCA) and to identify the root causes and their recommended actions. METHODS This retrospective observational study of RCA reports concerned events that occurred in VHA ICUs or as a result of ICU processes from January 1, 2013, through December 31, 2014. The type of event, root causes, and recommended actions were measured. RESULTS Some 70 eligible RCAs were identified in 47 of the 120 facilities with an ICU in the VHA system. Delays in care (30.0%) and medication errors (28.6%) were the most common types of events. There were 152 root causes and 277 recommended actions. Root causes often involved rules, policies, and procedure processes (28.3%), equipment/supply issues (15.8%), and knowledge deficits/education (15.1%). Common actions recommended were policy, procedure, and process actions (34.4%) and training/education actions (31.4%). Of the actions implemented, 84.4% had a reported effectiveness of "much better" or "better." CONCLUSION ICU adverse events often had several root causes, with protocols and process-of-care issues as root causes regardless of event type. Actions often included standardization of processes and training/education. Several recommendations can be made that may improve patient safety in the ICU, such as standardization of care process, implementation of team training programs, and simulation-based training.
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Duclos G, Zieleskiewicz L, Antonini F, Mokart D, Paone V, Po MH, Vigne C, Hammad E, Potié F, Martin C, Medam S, Leone M. Implementation of an electronic checklist in the ICU: Association with improved outcomes. Anaesth Crit Care Pain Med 2017; 37:25-33. [PMID: 28705759 DOI: 10.1016/j.accpm.2017.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 03/27/2017] [Accepted: 04/01/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess the impact of an electronic checklist during the morning rounds on ventilator-associated pneumonia (VAP) in the intensive care unit (ICU). PATIENTS AND METHODS We conducted a retrospective, before/after study in a single ICU of a university hospital. A systematic electronic checklist focusing on guidelines adherence was introduced in January 2012. From January 2008 to June 2014, we screened patients with ICU stay durations of at least 48hours. Propensity score-matched analysis with conditional logistic regression was used to compare the rate of VAP and number of days free of invasive devices before and after implementation of the electronic checklist. RESULTS We analysed 1711 patients (before group, n=761; after group, n=950). The rates of VAP were 21% and 11% in the before and after groups, respectively (p<0.001). In propensity-score matched analysis (n=742 in each group), VAP occurred in 151 patients (21%) during the before period compared with 72 patients (10%) during the after period (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.27-0.53). The after group showed increases in ICU-free days (OR=1.05; 95% CI=1.04-1.07) and mechanical ventilation-free days (OR=1.03; 95% CI=1.01-1.04). CONCLUSION In this matched before/after study, implementation of an electronic checklist was associated with positive effects on patient outcomes, especially on VAP. Further prospective studies are needed to confirm these observations.
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Affiliation(s)
- Gary Duclos
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Laurent Zieleskiewicz
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - François Antonini
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Djamel Mokart
- Service d'anesthésie et de réanimation, institut Paoli-Calmettes, 13015 Marseille, France
| | - Véronique Paone
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Marie Hélène Po
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Coralie Vigne
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Emmanuelle Hammad
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Frédéric Potié
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Claude Martin
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Sophie Medam
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Marc Leone
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France.
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Clinical audits to improve critical care: Part 1 Prepare and collect data. Aust Crit Care 2017; 31:101-105. [PMID: 28550968 DOI: 10.1016/j.aucc.2017.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 03/21/2017] [Accepted: 04/28/2017] [Indexed: 12/27/2022] Open
Abstract
Clinical audits are used to examine current practice, compare this with established best practice and implementing change, to ensure patients receive the most effective treatment. They are successful in improving the quality and safety of care provided, and thereby clinical outcomes. Clinical audits are ubiquitous throughout critical care practice, but without the necessary focus, engagement, preparation, method, evaluation and communication, they may be a waste of resources. This article is the first of a two-paper series regarding audits in critical care. The article provides an overview of the structures and processes needed to prepare and collect data for clinical audits, to make them as effective as possible to improve patient outcomes. This is accomplished through a practical step-by-step guide, including links to valuable resources, which are relevant to all critical care clinicians planning on undertaking clinical audits.
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Bodí M, Oliva I, Martín MC, Gilavert MC, Muñoz C, Olona M, Sirgo G. Impact of random safety analyses on structure, process and outcome indicators: multicentre study. Ann Intensive Care 2017; 7:23. [PMID: 28247300 PMCID: PMC5331020 DOI: 10.1186/s13613-017-0245-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 02/13/2017] [Indexed: 01/10/2023] Open
Abstract
Background
To assess the impact of a real-time random safety tool on structure, process and outcome indicators. Methods
Prospective study conducted over a period of 12 months in two adult patient intensive care units. Safety rounds were conducted three days a week ascertaining 37 safety measures (grouped into 10 blocks). In each round, 50% of the patients and 50% of the measures were randomized. The impact of this safety tool was analysed on indicators of structure (safety culture, healthcare protocols), process (improvement proportion related to tool application, IPR) and outcome (mortality, average stay, rate of catheter-related bacteraemias and rate of ventilator-associated pneumonia, VAP). Results A total of 1214 patient-days were analysed. Structure indicators: the use of the safety tool was associated with an increase in the safety climate and the creation/modification of healthcare protocols (sedation/analgesia and weaning). Process indicators: Twelve of the 37 measures had an IPR > 10%; six showed a progressive decrease in the IPR over the study period. Nursing workloads and patient severity on the day of analysis were independently associated with a higher IPR in half of the blocks of variables. Outcome indicators: A significant decrease in the rate of VAP was observed. Conclusions The real-time random safety tool improved the care process and adherence to clinical practice guidelines and was associated with an improvement in structure, process and outcome indicators. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0245-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- María Bodí
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain.,Instituto de Investigación Sanitaria Pere Virgili, Rovira i Virgili University, Tarragona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Iban Oliva
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain.
| | - Maria Cruz Martín
- Intensive Care Unit, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
| | | | - Carlos Muñoz
- Intensive Care Unit, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
| | - Montserrat Olona
- Instituto de Investigación Sanitaria Pere Virgili, Rovira i Virgili University, Tarragona, Spain.,Department of Preventive Medicine, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - Gonzalo Sirgo
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain.,Instituto de Investigación Sanitaria Pere Virgili, Rovira i Virgili University, Tarragona, Spain
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Maitra S. Checklist & prompting in intensive care unit: quality of care is improved but long way to go for better outcome. J Thorac Dis 2017; 9:228-229. [PMID: 28275465 DOI: 10.21037/jtd.2017.02.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Souvik Maitra
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Bodí M, Oliva I, Martín MC, Sirgo G. Real-time random safety audits: A transforming tool adapted to new times. Med Intensiva 2016; 41:368-376. [PMID: 27776937 DOI: 10.1016/j.medin.2016.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/30/2016] [Accepted: 09/06/2016] [Indexed: 02/02/2023]
Abstract
Real-time random safety audits constitute a tool designed to transfer knowledge from the sources of scientific evidence to the patient bedside. It has proven useful in critically ill patients, improving safety in the process of critical patient care, turning unsafe situations into safe ones in daily practice, and ensuring adherence to scientific evidence. In parallel, the design and methodology involved affords process indicators that will make it possible to know how we provide care for our patients, evolution over time (with regular feedback for professionals), the impact of our interventions, and benchmarking.
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Affiliation(s)
- M Bodí
- Intensive Care Unit, Hospital Universitario de Tarragona Joan XXIII, Tarragona, España; Instituto de Investigación Sanitaria Pere Virgili, Universitat Rovira i Virgili, Tarragona, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - I Oliva
- Intensive Care Unit, Hospital Universitario de Tarragona Joan XXIII, Tarragona, España
| | - M C Martín
- Intensive Care Unit, Hospital Universitario de Torrejón , Torrejón de Ardoz, Madrid, España
| | - G Sirgo
- Intensive Care Unit, Hospital Universitario de Tarragona Joan XXIII, Tarragona, España; Instituto de Investigación Sanitaria Pere Virgili, Universitat Rovira i Virgili, Tarragona, España
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Chen C, Kan T, Li S, Qiu C, Gui L. Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review. Am J Emerg Med 2016; 34:2432-2439. [PMID: 27742522 DOI: 10.1016/j.ajem.2016.09.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/20/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome. METHODS An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes. RESULTS The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients. CONCLUSIONS The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes.
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Affiliation(s)
- Chulin Chen
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
| | - Ting Kan
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
| | - Shuang Li
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
| | - Chen Qiu
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
| | - Li Gui
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
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Brolliar SM, Moore M, Thompson HJ, Whiteside LK, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Ng Boyle L, Mitchell PH, Rivara FP, Vavilala MS. A Qualitative Study Exploring Factors Associated with Provider Adherence to Severe Pediatric Traumatic Brain Injury Guidelines. J Neurotrauma 2016; 33:1554-60. [PMID: 26760283 PMCID: PMC5003009 DOI: 10.1089/neu.2015.4183] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Despite demonstrated improvement in patient outcomes with use of the Pediatric Traumatic Brain Injury (TBI) Guidelines (Guidelines), there are differential rates of adherence. Provider perspectives on barriers and facilitators to adherence have not been elucidated. This study aimed to identify and explore in depth the provider perspective on factors associated with adherence to the Guidelines using 19 focus groups with nurses and physicians who provided acute management for pediatric patients with TBI at five university-affiliated Level 1 trauma centers. Data were examined using deductive and inductive content analysis. Results indicated that three inter-related domains were associated with clinical adherence: 1) perceived guideline credibility and applicability to individual patients, 2) implementation, dissemination, and enforcement strategies, and 3) provider culture, communication styles, and attitudes towards protocols. Specifically, Guideline usefulness was determined by the perceived relevance to the individual patient given age, injury etiology, and severity and the strength of the evidence. Institutional methods to formally endorse, codify, and implement the Guidelines into the local culture were important. Providers wanted local protocols developed using interdisciplinary consensus. Finally, a culture of collaboration, including consistent, respectful communication and interdisciplinary cooperation, facilitated adherence. Provider training and experience, as well as attitudes towards other standardized care protocols, mirror the use and attitudes towards the Guidelines. Adherence was determined by the interaction of each of these guideline, institutional, and provider factors acting in concert. Incorporating provider perspectives on barriers and facilitators to adherence into hospital and team protocols is an important step toward improving adherence and ultimately patient outcomes.
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Affiliation(s)
- Sarah M Brolliar
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Megan Moore
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Hilaire J Thompson
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Lauren K Whiteside
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Richard B Mink
- 2 Harbor-University of California ; Los Angeles BioMedical Research Institute, Los Angeles, California
| | - Mark S Wainwright
- 3 Ann and Robert H. Lurie Children's Hospital of Chicago , Chicago, Illinois
| | | | | | - Christopher C Giza
- 6 Mattel Children's Hospital, University of California , Los Angeles, Los Angeles, California
| | - Douglas F Zatzick
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Richard G Ellenbogen
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Linda Ng Boyle
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Pamela H Mitchell
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Frederick P Rivara
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Monica S Vavilala
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
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Wessman BT, Sona C, Schallom M. A Novel ICU Hand-Over Tool: The Glass Door of the Patient Room. J Intensive Care Med 2016; 32:514-519. [PMID: 27271750 DOI: 10.1177/0885066616653947] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Poor communication among health-care providers is cited as the most common cause of sentinel events involving patients. Patient care in the critical care setting is incredibly complex. A consistent care plan is necessary between day/night shift teams and among bedside intensive care unit (ICU) nurses, consultants, and physicians. Our goal was to create a novel, easily accessible communication device to improve ICU patient care. METHODS This communication improvement project was done at an academic tertiary surgical/trauma/mixed 36-bed ICU with an average of 214 admissions per month. We created a glass door template embossed on the glass that included 3 columns for daily goals to be written: "day team," "night team," and "surgery/consultant team." Assigned areas for tracking "lines," "antibiotics," "ventilator weaning," and "Deep vein thrombosis (DVT) screening" were included. These doors are filled out/updated throughout the day by all of the ICU providers. All services can review current plans/active issues while evaluating the patient at the bedside. Patient-identifying data are not included. We retrospectively reviewed all ICU safety reported events over a 4-year period (2 years prior/2 years after glass door implementation) for specific handover communication-related errors and compared the 2 cohorts. RESULTS Information on the glass doors is entered daily on rounds by all services. Prior to implementation, 7.96% of reported errors were related to patient handover communication errors. The post glass-door era had 4.26% of reported errors related to patient handover communication errors with a relative risk reduction of 46.5%. Due to its usefulness, this method of communication was quickly adopted by the other critical care services (cardiothoracic, medical, neurology/neurosurgery, cardiology) at our institution and is now used for over 150 ICU beds. CONCLUSIONS Our glass door patient handover tool is an easily adaptable intervention that has improved communication leading to an overall decrease in the number of handover communication errors.
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Affiliation(s)
- Brian T Wessman
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.,2 Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carrie Sona
- 3 Department of Nursing, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Marilyn Schallom
- 4 Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
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Mckelvie BL, Mcnally JD, Menon K, Marchand MG, Reddy DN, Creery WD. A PICU patient safety checklist: rate of utilization and impact on patient care. Int J Qual Health Care 2016; 28:371-5. [DOI: 10.1093/intqhc/mzw042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2016] [Indexed: 12/22/2022] Open
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Sirvent JM, Gil M, Alvarez T, Martin S, Vila N, Colomer M, March E, Loma-Osorio P, Metje T. Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit of a reference hospital. Med Intensiva 2015; 40:266-72. [PMID: 26560019 DOI: 10.1016/j.medin.2015.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/19/2015] [Accepted: 08/03/2015] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To analyze whether the application of Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit (ICU) of a reference hospital. DESIGN Observational study with pre and post intervention analysis. SETTING ICU of a reference hospital. PATIENTS We design projects and a value stream map of flow and compared pre and post intervention. INTERVENTIONS We recorded demographic data, patient transfers by EMS for lack of beds and delay times in the discharge from ICU to ward. Multidisciplinary meetings and perform daily visual panel, with high priority ICU discharge. We promote temporary relocation of critically ill patients in other special areas of the hospital. We performed a professional satisfaction questionnaire with pre and post implementation of process. We make a statistical analysis of pre and post-intervention comparisons. RESULTS We planned for 2013 and progressively implemented in 2014. Analysis of patients entering the critical process flow 1) evaluate patients who must transfer for lack of beds, focusing on a diagnosis: pre 10/22 vs. 3/21 post (P=.045); 2) analysis of time delay in the discharge from the ICU to ward: 360.8±163.9minutes in the first period vs. 276.7±149.5 in the second (P=.036); and 3) personal professional satisfaction questionnaire, with 6.6±1.5 points pre vs. 7.5±1.1 in post (P=.001). Analysis of indicators such as the ICU acquired infections, length of ICU stay, the rate of re-admissions and mortality, with no significant differences between the two periods. CONCLUSIONS The application of Lean techniques in the critically ill process had a positive impact on improving patient flow within the health region, noting a decrease of transfers outside the region due to lack of beds, reduced delayed discharge from ICU to conventional ward and increased satisfaction of ICU professionals.
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Affiliation(s)
- J M Sirvent
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España.
| | - M Gil
- Actio-Consulting, Barcelona, España
| | - T Alvarez
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España
| | - S Martin
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España
| | - N Vila
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España
| | - M Colomer
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España
| | - E March
- Secretaría Técnica, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
| | - P Loma-Osorio
- Servicio de Cardiología, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
| | - T Metje
- Servicio de Anestesiología, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
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International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care. Neurocrit Care 2015; 21 Suppl 2:S215-28. [PMID: 25208666 DOI: 10.1007/s12028-014-0020-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.
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Critical Care Delivery: The Importance of Process of Care and ICU Structure to Improved Outcomes: An Update From the American College of Critical Care Medicine Task Force on Models of Critical Care. Crit Care Med 2015; 43:1520-5. [PMID: 25803647 DOI: 10.1097/ccm.0000000000000978] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.
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Bodí M, Olona M, Martín MC, Alceaga R, Rodríguez JC, Corral E, Pérez Villares JM, Sirgo G. Feasibility and utility of the use of real time random safety audits in adult ICU patients: a multicentre study. Intensive Care Med 2015; 41:1089-98. [PMID: 25869404 DOI: 10.1007/s00134-015-3792-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/31/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE The two aims of this study were first to analyse the feasibility and utility (to improve the care process) of implementing a new real time random safety tool and second to explore the efficacy of this tool in core hospitals (those participating in tool design) versus non-core hospitals. METHODS This was a prospective study conducted over a period of 4 months in six adult intensive care units (two of which were core hospitals). Safety audits were conducted 3 days per week during the entire study period to determine the efficacy of the 37 safety measures (grouped into ten blocks). In each audit, 50% of patients and 50% of measures were randomized. Feasibility was calculated as the proportion of audits completed over those scheduled and time spent, and utility was defined as the changes in the care process resulting from tool application. RESULTS A total of 1323 patient-days were analysed. In terms of feasibility, 87.6% of the scheduled audits were completed. The average time spent per audit was 34.5 ± 29 min. Globally, changes in the care process occurred in 5.4% of the measures analysed. In core hospitals, utility was significantly higher in 16 of the 37 measures, all of which were included in good clinical practice guidelines. Most of the clinical changes brought about by the tool occurred in the mechanical ventilation and haemodynamics blocks. Multivariate analyses demonstrated that changes in the care process in each block were associated with the core hospital variable, staffing ratios and severity of patient disease. CONCLUSIONS Real time safety audits improved the care process and adherence to the clinical practice guidelines and proved to be most useful in situations of high care load and in patients with more severe disease. The effect was greater in core hospitals.
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Affiliation(s)
- M Bodí
- Intensive Care Unit, Hospital Universitario Joan XXIII, Instituto de Investigación Sanitaria Pere Virgili, Rovira I Virgili University, Tarragona, Spain,
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