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You JY, Ligasaputri LD, Katamreddy A, Para K, Kavanagh E, Salgunan R, Gulani P. A Case-Control Study Evaluating the Impact of Dedicated Palliative Care Training on Critical Care Interventions at the end of Life. J Palliat Care 2024; 39:111-114. [PMID: 34397289 DOI: 10.1177/08258597211037436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many patients admitted to intensive care units (ICUs) are at high risk of dying. We hypothesize that focused training sessions for ICU providers by palliative care (PC) certified experts will decrease aggressive medical interventions at the end of life. We designed and implemented a 6-session PC training program in communication skills and goals of care (GOC) meetings for ICU teams, including house staff, critical care fellows, and attendings. We then reviewed charts of ICU patients treated before and after the intervention. Forty-nine of 177 (28%) and 63 of 173 (38%) patients were identified to be at high risk of death in the pre- and postintervention periods, respectively, and were included based on the study criteria. Inpatient mortality (45% vs 33%; P = .24) and need for mechanical ventilation (59% vs 44%, P = .13) were slightly higher in the preintervention population, but the difference was not statistically significant. The proportion of patients in whom the decision not to initiate renal replacement therapy was made because of poor prognosis was significantly higher in the postintervention population (14% vs 67%, P = .05). There was a nonstatistically significant trend toward earlier GOC discussions (median time from ICU admission to GOC 4 vs 3 days) and fewer critical care interventions such as tracheostomies (17% vs 4%, P = .19). Our study demonstrates that directed PC training of ICU teams has a potential to reduce end of life critical care interventions in patients with a poor prognosis.
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Affiliation(s)
- Jee Y You
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
| | - Lie D Ligasaputri
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
- University of California, San Francisco, USA
| | | | - Kiran Para
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
| | | | - Reka Salgunan
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
| | - Perminder Gulani
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
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Keats K, Sikora A, Heavner MS, Chen X, Smith SE. Optimizing Pharmacist Team-Integration for ICU Patient Management: Rationale, Study Design, and Methods for a Multicentered Exploration of Pharmacist-to-Patient Ratio. Crit Care Explor 2023; 5:e0956. [PMID: 37644971 PMCID: PMC10461940 DOI: 10.1097/cce.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The workload of healthcare professionals including physicians and nurses in the ICU has an established relationship to patient outcomes, including mortality, length of stay, and other quality indicators; however, the relationship of critical care pharmacist workload to outcomes has not been rigorously evaluated and determined. The objective of our study is to characterize the relationship of critical care pharmacist workload in the ICU as it relates to patient-centered outcomes of critically ill patients. METHODS Optimizing Pharmacist Team-Integration for ICU patient Management is a multicenter, observational cohort study with a target enrollment of 20,000 critically ill patients. Participating critical care pharmacists will enroll patients managed in the ICU. Data collection will consist of two observational phases: prospective and retrospective. During the prospective phase, critical care pharmacists will record daily workload data (e.g., census, number of rounding teams). During the retrospective phase, patient demographics, severity of illness, medication regimen complexity, and outcomes will be recorded. The primary outcome is mortality. Multiple methods will be used to explore the primary outcome including multilevel multiple logistic regression with stepwise variable selection to exclude nonsignificant covariates from the final model, supervised and unsupervised machine learning techniques, and Bayesian analysis. RESULTS Our protocol describes the processes and methods for an observational study in the ICU. CONCLUSIONS This study seeks to determine the relationship between pharmacist workload, as measured by pharmacist-to-patient ratio and the pharmacist clinical burden index, and patient-centered outcomes, including mortality and length of stay.
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Affiliation(s)
- Kelli Keats
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA
| | - Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA
| | - Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Xianyan Chen
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, GA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA
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Flinspach AN, Sterz J, Neef V, Flinspach MH, Zacharowski K, Ruesseler M, Janker L, Raimann FJ. Rise of public e-learning opportunities in the context of COVID-19 pandemic-induced curtailment of face-to-face courses, exemplified by epidural catheterization on YouTube. BMC MEDICAL EDUCATION 2023; 23:406. [PMID: 37277758 DOI: 10.1186/s12909-023-04409-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/29/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND In the context of the coronavirus pandemic, countless face-to-face events as well as medical trainings were cancelled or moved to online courses, which resulted in increased digitalization in many areas. In the context of medical education, videos provide tremendous benefit for visualizing skills before they are practised. METHODS Based on a previous investigation of video material addressing epidural catheterization available on the YouTube platform, we aimed to investigate new content produced in the context of the pandemic. Thus, a video search was conducted in May 2022. RESULTS We identified twelve new videos since the pandemic with a significant improvement in the new content in terms of procedural items (p = 0.03) compared to the prepandemic video content. Video content released in the course of the COVID-19 pandemic was more often created by private content creators and were significantly shorter in total runtime than those from university and medical societies (p = 0.04). CONCLUSION The profound changes in the learning and teaching of health care education in relation to the pandemic are largely unclear. We reveal improved procedural quality of predominantly privately uploaded content despite a shortened runtime compared to the prepandemic period. This might indicate that technical and financial hurdles to producing instructional videos by discipline experts have decreased. In addition to the teaching difficulties caused by the pandemic, this change is likely to be due to validated manuals on how to create such content. The awareness that medical education needs to be improved has grown, so platforms offer specialized sublevels for high-quality medical videos.
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Affiliation(s)
- Armin N Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt/Main, Germany.
| | - Jasmina Sterz
- Institute for Medical Didactics and Clinical Simulation, medical faculty, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt/Main, Germany
| | - Mairen H Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Sana Clinic Offenbach GmbH, Offenbach/Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt/Main, Germany
| | - Miriam Ruesseler
- Institute for Medical Didactics and Clinical Simulation, medical faculty, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Lena Janker
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt/Main, Germany
| | - Florian J Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt/Main, Germany
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Rahim Akroute A, Støre Brinchmann B, Hovland A, Dreyer Fredriksen ST. Registered nurses' experience of care for adult patients with a temporary tracheostomy at general hospital wards. A phenomenological-hermeneutic explorative study. Intensive Crit Care Nurs 2023; 77:103443. [PMID: 37116436 DOI: 10.1016/j.iccn.2023.103443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Caring for adult patients with a temporary tracheostomy in general wards can be challenging and complex. Little research has explored registered nurses' experiences with caring for these groups of patients. OBJECTIVES This study sought to interpret and describe registered nurses' lived experiences of caring for adult patients with a tracheostomy in general wards. RESEARCH DESIGN/METHODOLOGY Six registered nurses were interviewed in this study. The interviews were analysed to gain comprehensive knowledge about caring for adult patients with a temporary tracheostomy. The interviews were transcribed, analysed, and interpreted by using Gadameŕs philosophical hermeneutics and Kvale and Brinkmann's three steps of understanding. SETTING Three different wards medical, surgical, and neurological of a teaching hospital in Norway. FINDINGS Three themes emerged from data analysis. These included experiencing clinically challenging patients, a lack of clinical support from the intensive care nurses, and a lack of professional confidence. CONCLUSION This study highlighted the challenges surrounding the care of an adult patient with a tracheostomy in the general wards. Identifying these challenges would lead to further improvement in registered nurses' experiences and, in turn, in the quality of competent care for adult patients with a tracheostomy in the general ward. IMPLICATIONS FOR CLINICAL PRACTICE Understanding the registered nurses' experiences will assist the head nurses in planning and providing relevant information and education to provide safe and holistic patient care. Adequate support from intensive care unit nurses and professional development are required to ensure high-quality care. This study recommends that healthcare managers focus on establishing step-down units to improve patient outcomes, especially for high-risk patients and to increase the competencies of registered nurses in caring for adult patients with a tracheostomy as a whole person.
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Affiliation(s)
- Abder Rahim Akroute
- Department of Anesthesia and Intensive Care Medicine, Nordland Hospital, N-8049, Norway.
| | - Berit Støre Brinchmann
- The Faculty of Nursing and Health Sciences, Nord University, Bodø 8026, Norway; Nordland Hospital, Bodø 8076, Norway
| | | | - Sven-Tore Dreyer Fredriksen
- Nord University, Norway; Department of Health and Care Sciences, Faculty of Health Sciences, UiT. The Arctic University of Norway, Campus Harstad, Havnegata 5, Harstad 9480, Norway; Professional and Research Nurse at National Resource Center for Chronic Neurological Diseases, Knorrebakken Housing Units, Knorrebakken 2, Harstad 9411, Norway.
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Variation in Bed-to-Physician Ratios During Weekday Daytime Hours in ICUs in Australia and New Zealand. Crit Care Med 2022; 50:1737-1747. [PMID: 35862614 DOI: 10.1097/ccm.0000000000005623] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To determine common "bed-to-physician" ratios during weekday hours across ICUs and assess factors associated with variability in this ratio. DESIGN Retrospective cohort study. SETTING All ICUs in Australia/New Zealand that participated in a staffing survey administered in 2017-2018. PATIENTS ICU admissions from 2016 to 2018. METHODS We linked survey data with patient-level data. We defined: 1) bed-to-intensivist ratio as the number of usually available ICU beds divided by the number of onsite weekday daytime intensivists; and 2) bed-to-physician ratio as the number of available ICU beds divided by the total number of physicians (intensivists + nonintensivists, including trainees). We calculated the median and interquartile range (IQR) of bed-to-intensivist ratio and bed-to-physician ratios during weekday hours. We assessed variability in each by type of hospital and ICU and by severity of illness of patients, defined by the predicted hospital mortality. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 123 (87.2%) of Australia/New Zealand ICUs that returned staffing surveys, 114 (92.7%) had an intensivist present during weekday daytime hours, and 116 (94.3%) reported at least one nonintensivist physician. The median bed-to-intensivist ratio was 8.0 (IQR, 6.0-11.4), which decreased to a bed-to-physician ratio of 3.0 (IQR, 2.2-4.9). These ratios varied with mean severity of illness of the patients in the unit. The median bed-to-intensivist ratio was highest (13.5) for ICUs with a mean predicted mortality > 2-4%, and the median bed-to-physician ratio was highest (5.7) for ICUs with a mean predicted mortality of > 4-6%. Both ratios decreased and plateaued in ICUs with a mean predicted mortality for patients greater than 8% (median bed-to-intensivist ratio range, 6.8-8.0, and bed-to-physician ratio range of 2.4-2.7). CONCLUSIONS Weekday bed-to-physician ratios in Australia/New Zealand ICUs are lower than the bed-to-intensivist ratios and have a relatively fixed ratio of less than 3 for units taking care of patients with a higher average severity of illness. These relationships may be different in other countries or healthcare systems.
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Agarwal A, Ward NS. Can We Determine Optimal Dosing of Doctors in the ICU? Crit Care Med 2022; 50:1831-1833. [PMID: 36394401 PMCID: PMC9731370 DOI: 10.1097/ccm.0000000000005687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Nicholas S Ward
- Division of Pulmonary, Critical Care, and Sleep Medicine, Warren Alpert Medical School of Brown University, Providence, RI
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Agarwal A, Chen JT, Coopersmith CM, Denson JL, Dickert NW, Ferrante LE, Gershengorn HB, Gosine AD, Hayward BJ, Kaur N, Khan A, Lamberton C, Landsittel D, Lyons PG, Mikkelsen ME, Nadig NR, Pietropaoli AP, Poole BR, Viglianti EM, Sevransky JE. SWEAT ICU-An Observational Study of Physician Workload and the Association of Physician Outcomes in Academic ICUs. Crit Care Explor 2022; 4:e0774. [PMID: 36259061 PMCID: PMC9575792 DOI: 10.1097/cce.0000000000000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The optimal staffing model for physicians in the ICU is unknown. Patient-to-intensivist ratios may offer a simple measure of workload and be associated with patient mortality and physician burnout. To evaluate the association of physician workload, as measured by the patient-to-intensivist ratio, with physician burnout and patient mortality. DESIGN Cross-sectional observational study. SETTING Fourteen academic centers in the United States from August 2020 to July 2021. SUBJECTS We enrolled ICU physicians and collected data on adult ICU patients under the physician's care on the single physician-selected study day for each physician. MEASUREMENTS and MAIN RESULTS The primary exposure was workload (self-reported number of patients' physician was responsible for) modeled as high (>14 patients) and low (≤14 patients). The primary outcome was burnout, measured by the Well-Being Index. The secondary outcome measure was 28-day patient mortality. We calculated odds ratio for burnout and patient outcomes using a multivariable logistic regression model and a binomial mixed effects model, respectively. We enrolled 122 physicians from 62 ICUs. The median patient-to-intensivist ratio was 12 (interquartile range, 10-14), and the overall prevalence of burnout was 26.4% (n = 32). Intensivist workload was not independently associated with burnout (adjusted odds ratio, 0.74; 95% CI, 0.24-2.23). Of 1,322 patients, 679 (52%) were discharged alive from the hospital, 257 (19%) remained hospitalized, and 347 (26%) were deceased by day 28; 28-day outcomes were unknown for 39 of patients (3%). Intensivist workload was not independently associated with 28-day patient mortality (adjusted odds ratio, 1.33; 95% CI, 0.92-1.91). CONCLUSIONS In our cohort, approximately one in four physicians experienced burnout on the study day. There was no relationship be- tween workload as measured by patient-to-intensivist ratio and burnout. Factors other than the number of patients may be important drivers of burnout among ICU physicians.
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Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Jen-Ting Chen
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Craig M Coopersmith
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Joshua L Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Neal W Dickert
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Hayley B Gershengorn
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Adhiraj D Gosine
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Bradley J Hayward
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Navneet Kaur
- Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Akram Khan
- Division of Pulmonary Critical Care, Oregon Health and Science University, Portland, OR
| | - Courtney Lamberton
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Douglas Landsittel
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN
| | - Patrick G Lyons
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Mark E Mikkelsen
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Nandita R Nadig
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Anthony P Pietropaoli
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Brian R Poole
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Elizabeth M Viglianti
- Division Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
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Association of patient-to-intensivist ratio with hospital mortality in Australia and New Zealand. Intensive Care Med 2021; 48:179-189. [PMID: 34854939 PMCID: PMC8638228 DOI: 10.1007/s00134-021-06575-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/30/2021] [Indexed: 11/29/2022]
Abstract
Purpose The impact of intensivist workload on intensive care unit (ICU) outcomes is incompletely described and assessed across healthcare systems and countries. We sought to examine the association of patient-to-intensivist ratio (PIR) with hospital mortality in Australia/New Zealand (ANZ) ICUs. Methods We conducted a retrospective study of adult admissions to ANZ ICUs (August 2016–June 2018) using two cohorts: “narrow”, based on previously used criteria including restriction to ICUs with a single daytime intensivist; and “broad”, refined by individual ICU daytime staffing information. The exposure was average daily PIR and the outcome was hospital mortality. We used summary statistics to describe both cohorts and multilevel multivariable logistic regression models to assess the association of PIR with mortality. In each, PIR was modeled using restricted cubic splines to allow for non-linear associations. The broad cohort model included non-PIR physician and non-physician staffing covariables. Results The narrow cohort of 27,380 patients across 67 ICUs (predicted mortality: median 1.2% [IQR 0.4–1.4%]; mean 5.9% [sd 13.2%]) had a median PIR of 10.1 (IQR 7–14). The broad cohort of 91,206 patients across 73 ICUs (predicted mortality: 1.9% [0.6–6.5%]; 7.6% [14.9%]) had a median PIR of 7.8 (IQR 5.8–10.2). We found no association of PIR with mortality in either the narrow (PIR 1st spline term odds ratio [95% CI]: 1 [0.94, 1.06], Wald testing of spline terms p = 0.61) or the broad (1.02 [0.97, 1.07], p = 0.4) cohort. Conclusion We found no association of PIR with hospital mortality across ANZ ICUs. The low cohort predicted mortality may limit external validity. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06575-z.
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Guan X, Ni B, Zhang J, Zhu D, Cai Z, Meng W, Shi L, Ross-Degnan D. Association Between Physicians' Workload and Prescribing Quality in One Tertiary Hospital in China. J Patient Saf 2021; 17:e1860-e1865. [PMID: 32773646 DOI: 10.1097/pts.0000000000000753] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alarming increasing trends in physician workload have attracted much attention in recent years. Heavy workload may compromise the quality of medication use. Previous studies have identified a series of factors contributing to inappropriate prescribing; however, there is no demonstrated evidence supporting an association between workload and the appropriateness of physicians' prescriptions in China. This study aimed to investigate the relationship between physician workload and prescription quality in a tertiary hospital in Beijing, China. METHODS Our study was a single-center, retrospective study, with all outpatient electronic health records extracted from hospital information system of a tertiary hospital in Beijing from July 1 to November 30, 2015. We used outpatient volume in each 5-hour shift as the measure of physician workload. The evaluation of prescribing quality was based on the Rational Drug Use System. Generalized linear models with a γ distribution and a log link were used to explore factors associated with inappropriate prescribing, and we undertook a series of robustness tests with respect to different exclusion criteria. RESULTS A total of 457,784 prescriptions from 502 physicians were included in the study. Physicians had an average workload of 34.3 (±19.8) patients per shift, and the mean rate of inappropriate prescribing per shift was 14.1% (±14.6%). Higher rates of inappropriate prescribing were associated with heavier workloads (P < 0.001). Physicians who worked in the afternoon, chief physicians, those working in surgical department, males, and those with more than 20-year experience had higher rates of inappropriate prescribing with increasing workload. CONCLUSIONS Heavier workload was associated with higher risk of prescribing inappropriately. It requires great efforts to determine optimal physician workloads and mitigate the potential adverse effects on the prescription quality.
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Affiliation(s)
| | - Bingyu Ni
- From the Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences
| | - Jingyuan Zhang
- From the Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences
| | | | | | - Wenshuang Meng
- Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | | | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Abstract
Background: In July of 2013, the University of Maryland launched MarylandCCProject.com. This free-access educational website delivers asynchronous high-quality multidisciplinary critical care education targeted at critical care trainees. The lectures, presented in real time on-site, are recorded and available on the website or as a podcast on iTunes or Android. Thus, the curriculum can be easily accessed around the world. Objective: We sought to identify the impact this website has on current and former University of Maryland critical care trainees. Methods: A 32-question survey was generated using a standard survey generation tool. The survey was e-mailed in the fall of 2019 to the University of Maryland Multi-Departmental Critical Care current and graduated trainees from the prior 7 years. Survey data were collected through December 2019. The questions focused on user demographics, overall experience with the website, scope of website use, and clinical application of the content. Anonymous responses were electronically gathered. Results: A total of 186 current trainees and graduates were surveyed, with a 39% (n = 72) response rate. Of responders, 76% (55) use the website for ongoing medical education. The majority use the website at least monthly. Most users (63%, n = 35) access the lectures directly through the website. All 55 current users agree that the website has improved their medical knowledge and is a useful education resource. Platform use has increased and includes users from around the world. Conclusion: Based on our current data, the MarylandCCProject remains a valuable and highly used educational resource, impacting patient care both during and after critical care fellowship training.
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Martz K, Alderden J, Bassett R, Swick D. Outcomes Associated With a Nurse-Driven Palliative Care Screening Tool in the Intensive Care Unit. Crit Care Nurse 2021; 40:23-29. [PMID: 32476026 DOI: 10.4037/ccn2020702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Access to specialty palliative care delivery in the intensive care unit is inconsistent across institutions. The intensive care unit at the study institution uses a screening tool to identify patients likely to benefit from specialty palliative care, yet little is known about outcomes associated with the use of screening tools. OBJECTIVE To identify outcomes associated with specialty palliative care referral among patients with critical illness. METHODS Records of 112 patients with positive results on palliative care screening were retrospectively reviewed to compare outcomes between patients who received a specialty palliative care consult and those who did not. Primary outcome measures were length of stay, discharge disposition, and escalation of care. RESULTS Sixty-five patients (58%) did not receive a palliative care consult. No significant differences were found in length of hospital or intensive care unit stay. Most patients who experienced mechanical ventilation did not receive a palliative care consultation (χ2 = 5.14, P = .02). Patients who were discharged to home were also less likely to receive a consult (χ2 = 4.1, P = .04), whereas patients who were discharged to hospice were more likely to receive a consult (χ2 = 19.39, P < .001). CONCLUSIONS Unmet needs exist for specialty palliative care. Understanding the methods of identifying patients for specialty palliative care and providing them with such care is critically important. Future research is needed to elucidate the factors providers use in their decisions to order or defer specialty palliative care consultation.
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Affiliation(s)
- Kim Martz
- Kim Martz is Associate Professor Emeritus, Boise State University School of Nursing, Faculty Mentor, St Luke's Health System, Boise, Idaho
| | - Jenny Alderden
- Jenny Alderden is an assistant professor, University of Utah College of Nursing, Salt Lake City, Utah
| | - Rick Bassett
- Rick Bassett is an adult clinical nurse specialist, St Luke's Health System
| | - Dawn Swick
- Dawn Swick is a staff nurse, St Luke's Health System
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Leenstra NF, Johnson A, Jung OC, Holman ND, Hofstra LS, Tulleken JE. Challenges for conducting and teaching handovers as collaborative conversations: an interview study at teaching ICUs. PERSPECTIVES ON MEDICAL EDUCATION 2018; 7:302-310. [PMID: 30187389 PMCID: PMC6191396 DOI: 10.1007/s40037-018-0448-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Whereas medical shift handovers are increasingly recognized to fulfil important functions beyond information transfer, studies suggest that shift handovers continue to be variably used for reflection, learning or discussion. Little is known of the dynamics of incorporating such functions into ICU shift handovers, resulting in a challenge for the design of educational programs whose underlying philosophies align with the specific requirements of the ICU. METHODS Intensivists, residents and fellows (n = 21) from three ICUs were interviewed to determine perceptions of handover functionality and the boundaries to what must or can be achieved in handover conversations. Interviews were analyzed to isolate training requirements and factors that challenge interactions. RESULTS The analysis revealed that ICU physicians value three functions for shift handovers: information transfer, enhancing shared understanding and decision-making, and learning. The functions towards which physicians are oriented were found to be affected by situational characteristics of cases, individuals, teams, and the unit workflow. Whereas some factors are helpful cues for determining communication needs, others raise dilemmas and misaligned expectations with regards to what can be achieved in the handover. DISCUSSION Our findings add to the growing case for the education of handovers in complex settings to involve more than information transfers. As residents gain experience, training should be gradually shifted towards more fluid and adaptable approaches to the handover and residents' ability to engage in joint reflections and discussions. Challenges for engaging in such interactions need to be alleviated, in order to allow the redefinition of handovers as potential sources of safety and learning, rather than error.
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Affiliation(s)
- Nico F Leenstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Addie Johnson
- Department of Psychology, University of Groningen, Groningen, The Netherlands
| | - Oliver C Jung
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole D Holman
- Department of Intensive Care, Martini Hospital Groningen, Groningen, The Netherlands
| | - Lieuwe S Hofstra
- Department Intensive Care Medicine, Scheper Hospital, Emmen, The Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Abstract
Intensive care units (ICUs) provide care to the most severely ill hospitalized patients. Although ICUs increasingly rely on interprofessional teams to provide critical care, little about actual teamwork in this context is well understood. The ICU team is typically comprised of physicians or intensivists, clinical pharmacists, respiratory therapists, dieticians, bedside nurses, clinical psychologists, and clinicians-in-training. ICU teams are distinguished from other health care teams in that they are low in temporal stability, which can impede important team dynamics. Furthermore, ICU teams must work in physically and emotionally challenging environments. Our review of the literature reveals the importance of information sharing and decision-making processes, and identifies potential barriers to successful team performance, including the lack of effective conflict management and the presence of multiple and sometimes conflicting goals. Key knowledge gaps about ICU teams include the need for more actionable data linking ICU team structure to team functioning and patient-, family-, ICU-, and hospital-level outcomes. In particular, research is needed to better delineate and define the ICU team, identify additional psychosocial phenomena that impact ICU team performance, and address varying and often competing indicators of ICU team effectiveness as a multivariate and multilevel problem that requires better understanding of the independent effects and interdependencies between nested elements (i.e., hospitals, ICUs, and ICU teams). Ultimately, efforts to advance team-based care are essential for improving ICU performance, but more work is needed to develop actionable interventions that ensure that critically ill patients receive the best care possible. (PsycINFO Database Record
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Affiliation(s)
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh
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Heincelman M, Duckett A, Keith B, Schreiner A, Zhang J, Kilb E, Clyburn B. The Structure of Medical Intensive Care Units at Training Institutions. Am J Med Sci 2018; 355:396-401. [PMID: 29661355 DOI: 10.1016/j.amjms.2017.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND As a result of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour guideline implementation, the structure of intensive care unit (ICU) teams at training institutions has been affected. The impact these changes have had on the current work environment has not been well described. METHODS The authors conducted an online survey of internal medicine program directors in 2016. The survey investigated how training institutions structure their intensive care units in reference to volume, resident housestaff and alternative coverage options, with a focus on changes made after the implementation of the 2011 ACGME duty hour restrictions. RESULTS Notable differences were found in program director responses to coverage of patients in the ICUs. A total of 62 of the 132 (48%) responding program directors describe coverage of all patients solely by resident housestaff. Since 2011, 54 (41%) programs have increased the number of resident physicians rotating in the ICU per month and initiated or increased the use of nonresident coverage of patients. Use of non-resident providers is not associated with a decrease in the number of total ICU months per resident or a decrease in educational value. CONCLUSIONS Since the 2011 ACGME duty hour implementation, there is wide variability in the learning environment of medical intensive care units in training institutions.
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Affiliation(s)
- Marc Heincelman
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Ashley Duckett
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Brad Keith
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Andrew Schreiner
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jingwen Zhang
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Edward Kilb
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Benjamin Clyburn
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
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16
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Castro R, Nin N, Ríos F, Alegría L, Estenssoro E, Murias G, Friedman G, Jibaja M, Ospina-Tascon G, Hurtado J, Marín MDC, Machado FR, Cavalcanti AB, Dubin A, Azevedo L, Cecconi M, Bakker J, Hernandez G. The practice of intensive care in Latin America: a survey of academic intensivists. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:39. [PMID: 29463310 PMCID: PMC5820791 DOI: 10.1186/s13054-018-1956-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 01/16/2018] [Indexed: 12/29/2022]
Abstract
Background Intensive care medicine is a relatively young discipline that has rapidly grown into a full-fledged medical subspecialty. Intensivists are responsible for managing an ever-increasing number of patients with complex, life-threatening diseases. Several factors may influence their performance, including age, training, experience, workload, and socioeconomic context. The aim of this study was to examine individual- and work-related aspects of the Latin American intensivist workforce, mainly with academic appointments, which might influence the quality of care provided. In consequence, we conducted a cross-sectional study of intensivists at public and private academic and nonacademic Latin American intensive care units (ICUs) through a web-based electronic survey submitted by email. Questions about personal aspects, work-related topics, and general clinical workflow were incorporated. Results Our study comprised 735 survey respondents (53% return rate) with the following country-specific breakdown: Brazil (29%); Argentina (19%); Chile (17%); Uruguay (12%); Ecuador (9%); Mexico (7%); Colombia (5%); and Bolivia, Peru, Guatemala, and Paraguay combined (2%). Latin American intensivists were predominantly male (68%) young adults (median age, 40 [IQR, 35–48] years) with a median clinical ICU experience of 10 (IQR, 5–20) years. The median weekly workload was 60 (IQR, 47–70) h. ICU formal training was between 2 and 4 years. Only 63% of academic ICUs performed multidisciplinary rounds. Most intensivists (85%) reported adequate conditions to manage patients with septic shock in their units. Unsatisfactory conditions were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and drug shortages (5%). Seventy percent of intensivists participated in research, and 54% read scientific studies regularly, whereas 32% read no more than one scientific study per month. Research grants and pharmaceutical sponsorship are unusual funding sources in Latin America. Although Latin American intensivists are mostly unsatisfied with their income (81%), only a minority (27%) considered changing to another specialty before retirement. Conclusions Latin American intensivists constitute a predominantly young adult workforce, mostly formally trained, have a high workload, and most are interested in research. They are under important limitations owing to resource constraints and overt dissatisfaction. Latin America may be representative of other world areas with similar challenges for intensivists. Specific initiatives aimed at addressing these situations need to be devised to improve the quality of critical care delivery in Latin America. Electronic supplementary material The online version of this article (10.1186/s13054-018-1956-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Diagonal Paraguay #362, Santiago Centro, RM, 8330077, Chile. .,Unidad de Paciente Critico Adultos, Hospital Clinico UC-CHRISTUS, Marcoleta #367, Santiago Centro, RM, 8330077, Chile.
| | - Nicolas Nin
- Hospital Español, Avenida General Garibaldi, 1729 esq., Rocha, Montevideo, Uruguay.,Agencia Nacional de Investigación e Innovación (ANII), Montevideo, Uruguay
| | - Fernando Ríos
- Servicio de Terapia Intensiva. Hospital Alejandro Posadas, Avenida Presidente Arturo U. Illia, El Palomar, Buenos Aires, Argentina
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Diagonal Paraguay #362, Santiago Centro, RM, 8330077, Chile
| | - Elisa Estenssoro
- Servicio de Terapia Intensiva, Hospital Interzonal de Agudos General San Martin de La Plata, Avenida 1 1794, Casco Urbano, La Plata, Buenos Aires, B1904CFU, Argentina
| | - Gastón Murias
- Clinica Bazterrica and Clinica Santa Isabel, Billinghurst 2072 (esquina Juncal), Ciudad Autónoma de Buenos Aires, Argentina
| | - Gilberto Friedman
- Departamento de Medicina Interna - Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350 - Santa Cecilia, Porto Alegre, RS, 90035-903, Brasil
| | - Manuel Jibaja
- Escuela de Medicina, Universidad Internacional del Ecuador, Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Avenida Gran Colombia, Quito, 170136, Ecuador
| | - Gustavo Ospina-Tascon
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Cali, Carrera 98 No. 18-49, Cali, Valle del Cauca, Colombia
| | - Javier Hurtado
- Hospital Español, Avenida General Garibaldi, 1729 esq., Rocha, Montevideo, Uruguay.,Agencia Nacional de Investigación e Innovación (ANII), Montevideo, Uruguay
| | - María Del Carmen Marín
- Unidad de Cuidados Intensivos, Hospital Regional 1 Octubre, ISSSTE, Avenida Instituto Politécnico Nacional 1669. Colonia Lindavista, c.p., Delegación Gustavo A. Madero, Ciudad de México, 07300, México
| | - Flavia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Rua Sena Madureira, 1500 - Clementino, São Paulo, SP, 04021-001, Brasil
| | - Alexandre Biasi Cavalcanti
- Research Institute HCor, Hospital do Coração, Rua. Desembargador Eliseu Guilherme, 147 - Paraíso, São Paulo, SP, 04004-030, Brasil
| | - Arnaldo Dubin
- Catedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina.,Servicio de Terapia Intensiva, Sanatorio Otamendi y Miroli, Azcuénaga 894, CABA, C1115AAB, Argentina
| | - Luciano Azevedo
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil.,Emergency Medicine Department, University of Sao Paulo, Hospital Sirio-Libanes, Rua Dona Adma Jafet, 91 - Vista, Sao Paulo, SP, 01308-050, Brasil
| | - Maurizio Cecconi
- St. George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Jan Bakker
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Diagonal Paraguay #362, Santiago Centro, RM, 8330077, Chile.,Unidad de Paciente Critico Adultos, Hospital Clinico UC-CHRISTUS, Marcoleta #367, Santiago Centro, RM, 8330077, Chile
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Norman MK. Twelve tips for reducing production time and increasing long-term usability of instructional video. MEDICAL TEACHER 2017; 39:808-812. [PMID: 28485662 PMCID: PMC6262844 DOI: 10.1080/0142159x.2017.1322190] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The use of instructional video is increasing across all disciplines and levels of education. Although video has a number of distinct advantages for course delivery and student learning, it can also be time-consuming and resource-intensive to produce, which imposes a burden on busy faculty. With video poised to play a larger role in medical education, we need strategies for streamlining video production and ensuring that the video we produce is of lasting value. This article draws on learning research and best practices in educational technology, along with the author's experience in online education and video production. It offers 12 practical tips for reducing the initial time investment in video production and creating video that can be reused long into the future. These tips can help faculty and departments create high-quality instructional video while using their time and resources more wisely.
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Affiliation(s)
- Marie K Norman
- a Institute for Clinical Research Education, School of Medicine, University of Pittsburgh , Pittsburgh , PA , USA
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19
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Tainter CR, Wong NL, Cudemus-Deseda GA, Bittner EA. The "Flipped Classroom" Model for Teaching in the Intensive Care Unit. J Intensive Care Med 2016; 32:187-196. [PMID: 26912409 DOI: 10.1177/0885066616632156] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The intensive care unit (ICU) is a dynamic and complex learning environment. The wide range in trainee's experience, specialty training, fluctuations in patient acuity and volume, limitations in trainee duty hours, and additional responsibilities of the faculty contribute to the challenge in providing a consistent experience with traditional educational strategies. The "flipped classroom" is an educational model with the potential to improve the learning environment. In this paradigm, students gain exposure to new material outside class and then use class time to assimilate the knowledge through problem-solving exercises or discussion. The rationale and pedagogical foundations for the flipped classroom are reviewed, practical considerations are discussed, and an example of successful implementation is provided. METHODS An education curriculum was devised and evaluated prospectively for teaching point-of-care echocardiography to residents rotating in the surgical ICU. RESULTS Preintervention and postintervention scores of knowledge, confidence, perceived usefulness, and likelihood of use the skills improved for each module. The quality of the experience was rated highly for each of the sessions. CONCLUSION The flipped classroom education curriculum has many advantages. This pilot study was well received, and learners showed improvement in all areas evaluated, across several demographic subgroups and self-identified learning styles.
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Halkett G, McKay J, Hegney D, Breen LJ, Berg M, Ebert M, Davis M, Kearvell R. Radiation therapists' and radiation oncology medical physicists' perceptions of work and the working environment in Australia: a qualitative study. Eur J Cancer Care (Engl) 2016; 26. [DOI: 10.1111/ecc.12511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2016] [Indexed: 11/29/2022]
Affiliation(s)
- G.K.B. Halkett
- School of Nursing and Midwifery; Faculty of Health Sciences; Curtin University; Perth Western Australia
| | - J. McKay
- Discipline of Medical Radiation Science; Faculty of Science and Engineering; Curtin University; Perth Western Australia
| | - D.G. Hegney
- School of Nursing and Midwifery; The University of Southern Queensland; Darling Heights Queensland Australia
- School of Nursing; The University of Adelaide; Adelaide South Australia
| | - Lauren J. Breen
- School of Psychology and Speech Pathology; Faculty of Health Sciences; Curtin University; Perth Western Australia
| | - M. Berg
- School of Nursing and Midwifery; Faculty of Health Sciences; Curtin University; Perth Western Australia
| | - M.A. Ebert
- Department of Radiation Oncology; Sir Charles Gairdner Hospital; Nedlands Western Australia
- School of Physics; University of Western Australia; Crawley Western Australia
| | - M. Davis
- Genesis Cancer Care; Perth Western Australia
| | - R. Kearvell
- Department of Radiation Oncology; Sir Charles Gairdner Hospital; Nedlands Western Australia
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Momennasab M, Ghahramani T, Yektatalab S, Zand F. Physical and Mental Health of Patients Immediately After Discharge From Intensive Care Unit and 24 Hours Later. Trauma Mon 2016; 21:e29231. [PMID: 27218059 PMCID: PMC4869429 DOI: 10.5812/traumamon.29231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/20/2015] [Accepted: 08/30/2015] [Indexed: 12/28/2022] Open
Abstract
Background: Monitoring the health status of patients discharged from intensive care units is a crucial method of service evaluation. Objectives: This study aimed to assess the physical and mental health status of patients immediately after discharge from the ICU and 24 hours later. Patients and Methods: This descriptive comparative study was conducted on 104 patients discharged from the ICUs of a referral trauma center in Shiraz, Southwest Iran. Physical parameters, including respiratory rate, need for supplemental oxygen, heart rate, blood pressure, and need for cardiac monitoring, were assessed. Hospital anxiety and depression scale (HADS) was used for mental health evaluation. The mental and physical status of patients were assessed before ICU discharge and 24 hours later; data were recorded in information forms and were analyzed using SPSS statistical software version 17. Results: At the time of discharge, the respiratory rate of 28% of the participants was more than 24 minutes, and 95.2% received supplemental oxygen. However, after 24 hours these values decreased to 10% and 21.6%, respectively. The mean heart rate and systolic blood pressure were within the normal range at both time points. Additionally, 63% of the patients had anxiety scores above 11 at both time points, reflecting high anxiety. The number of patients who reported depression increased from 58.7% at ICU discharge to 69.6% after 24 hours. Conclusions: Despite the considerable improvement in most of the patients’ physical condition in the first 24 hours after discharge from ICU, a significant number of them remain at risk for the development of adverse effects from this transition. The high prevalence of mental health disorders in these patients reveals the necessity to conduct follow-up consultations.
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Affiliation(s)
- Marzieh Momennasab
- Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding author: Marzieh Momennasab, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel: +98-7116474256, Fax: +98-7116474252, E-mail:
| | - Tahereh Ghahramani
- Student Research Committee, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Shahrzad Yektatalab
- Psychiatric Care Research Center, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
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Landsperger JS, Semler MW, Wang L, Byrne DW, Wheeler AP. Outcomes of Nurse Practitioner-Delivered Critical Care: A Prospective Cohort Study. Chest 2015; 149:1146-54. [PMID: 26836900 DOI: 10.1016/j.chest.2015.12.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 11/25/2015] [Accepted: 12/14/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Acute care nurse practitioners (ACNPs) are increasingly being employed in ICUs to offset physician shortages, but no data exist about outcomes of critically ill patients continuously cared for by ACNPs. METHODS Prospective cohort study of all admissions to an adult medical ICU in an academic, tertiary-care center between January 1, 2011, and December 31, 2013. The primary end point of 90-day survival was compared between patients cared for by ACNP and resident teams using Cox proportional hazards regression. Secondary end points included ICU and hospital mortality and ICU and hospital length of stay. RESULTS Among 9,066 admissions, there was no difference in 90-day survival for patients cared for by ACNP or resident teams (adjusted hazard ratio [HR], 0.94; 95% CI, 0.85-1.04; P = .21). Although patients cared for by ACNPs had lower ICU mortality (6.3%) than resident team patients (11.6%; adjusted OR, 0.77; 95% CI, 0.63-0.94; P = .01), hospital mortality was not different (10.0% vs 15.9%; adjusted OR, 0.87; 95% CI, 0.73-1.03; P = .11). ICU length of stay was similar between the ACNP and resident teams (3.4 ± 3.5 days vs 3.7 ± 3.9 days [adjusted OR, 1.01; 95% CI, 0.93-1.1; P = .81]), but hospital length of stay was shorter for patients cared for by ACNPs (7.9 ± 11.2 days) than for resident patients (9.1 ± 11.2 days) (adjusted OR, 0.87; 95% CI, 0.80-0.95; P = .001). CONCLUSION Outcomes are comparable for critically ill patients cared for by ACNP and resident teams.
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Affiliation(s)
- Janna S Landsperger
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | - Matthew W Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Daniel W Byrne
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Arthur P Wheeler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Dandoy CE, Hausfeld J, Flesch L, Hawkins D, Demmel K, Best D, Osterkamp E, Bracke T, Nagarajan R, Jodele S, Holt J, Giaccone MJ, Davies SM, Kotagal U, Simmons J. Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children’s hospital: a time series analysis. BMJ Qual Saf 2015; 25:633-43. [DOI: 10.1136/bmjqs-2015-004450] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 10/24/2015] [Indexed: 11/04/2022]
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Abstract
PURPOSE OF REVIEW Growth in critical care services has led to a dramatic increase in the need for ICU physicians. The supply of intensivists is not easily increased and there is pressure to solve this problem by increasing the number of patients per intensivist. There is a scarcity of published data addressing this issue, and until recently, there were no guidelines on appropriate ratios of intensivists to patients. RECENT FINDINGS In 2013, the Society of Critical Care Medicine formed a task force to address this issue and published written guidelines to aid hospitals in determining their intensivist staffing. This study reviews the published data which can aid these decisions and summarize the SCCM Taskforce's recommendations. SUMMARY The complex nature of critical care patients and ICUs make it difficult to provide one specific maximum intensivist-to-patient ratio, but common-sense rules can be applied. These recommendations are predicated on the principles that staffing can impact patient care as well as staff well-being and workforce stability. Also, that worsening patient outcomes, teaching, and workforce issues can be markers of inappropriate staffing. Finally, if the predicted daily workload of an intensivist exceeds the time of a work shift, then adjustments need to be made.
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County-Level Effects of Prehospital Regionalization of Critically Ill Patients: A Simulation Study. Crit Care Med 2015; 43:1807-15. [PMID: 26102251 DOI: 10.1097/ccm.0000000000001133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Regionalization may improve critical care delivery, yet stakeholders cite concerns about its feasibility. We sought to determine the operational effects of prehospital regionalization of nontrauma, nonarrest critical illness. SETTING King County, Washington. DESIGN Discrete event simulation study. PATIENTS All 2006 hospital discharge data, linked to all adult, eligible patients transported by county emergency medical services agencies. INTERVENTIONS We simulated active triage of high-risk patients to designated referral centers using a validated prehospital risk score; we studied three regionalization scenarios: 1) up triage, 2) up and down triage, and 3) up and down triage after reducing ICU beds by 25%. We determined the effect on patient routing, ICU occupancy at referral and nonreferral hospitals, and emergency medical services transport times. MEASUREMENTS AND MAIN RESULTS A total of 119,117 patients were hospitalized at 11 nonreferral centers and 76,817 patients were hospitalized at three referral centers. Among 20,835 emergency medical services patients, 7,817 patients (43%) were eligible for up triage and 10,242 patients (57%) were eligible for down triage. At baseline, mean daily ICU bed occupancy was 61% referral and 47% at nonreferral hospitals. Up triage increased referral ICU occupancy to 68%, up and down triage to 64%, and up and down triage with bed reduction to 74%. Mean daily nonreferral ICU occupancy did not exceed 60%. Total emergency medical services transport time increased by less than 3% with up and down triage. CONCLUSIONS Regionalization based on prehospital triage of the critically ill can allocate high-risk patients to referral hospitals without adversely affecting ICU occupancy or prehospital travel time.
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Richman PS, Saft HL, Messina CR, Berman AR, Selecky PA, Mularski RA, Ray DE, Ford DW. Palliative and end-of-life educational practices in US pulmonary and critical care training programs. J Crit Care 2015; 31:172-7. [PMID: 26507641 DOI: 10.1016/j.jcrc.2015.09.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 09/22/2015] [Accepted: 09/27/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE To describe educational features in palliative and end-of-life care (PEOLC) in pulmonary/critical care fellowships and identify the features associated with perceptions of trainee competence in PEOLC. METHODS A survey of educational features in 102 training programs and the perceived skill and comfort level of trainees in 6 PEOLC domains: communication, symptom control, ethical/legal, community/institutional resources, specific syndromes, and ventilator withdrawal. We evaluated associations between perceived trainee competence/comfort in PEOLC and training program features, using regression analyses. RESULTS Fifty-five percent of program directors (PDs) reported faculty with training in PEOLC; 30% had a written PEOLC curriculum. Neither feature was associated with trainee competence/comfort. Program directors and trainees rated bedside PEOLC teaching highly. Only 20% offered PEOLC rotations; most trainees judged these valuable. Most PDs and trainees reported that didactic teaching was insufficient in communication, although sufficient teaching of this was associated with perceived trainee competence in communication. Perceived trainee competence in managing institutional resources was rated poorly. Program directors reporting significant barriers to PEOLC education also judged trainees less competent in PEOLC. Time constraint was the greatest barrier. CONCLUSION This survey of PEOLC education in US pulmonary/critical care fellowships identified associations between certain program features and perceived trainee skill in PEOLC. These results generate hypotheses for further study.
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Affiliation(s)
- Paul S Richman
- Pulmonary/Critical Care Division, Stony Brook University, Stony Brook, NY.
| | - Howard L Saft
- Pulmonary Critical Care Division, Veterans Affairs Healthcare of Greater Los Angeles, Los Angeles, CA.
| | - Catherine R Messina
- Department of Preventative Medicine, Stony Brook University, Stony Brook University, Stony Brook, NY.
| | - Andrew R Berman
- Division of Pulmonary & Critical Care Medicine and Allergic & Immunologic Diseases, University Hospital Building, New Jersey Medical School, Newark, NJ, 07103.
| | - Paul A Selecky
- Hoag Memorial Hospital, Newport Beach, and the University of California at Los Angeles, Newport Beach, CA.
| | | | | | - Dee W Ford
- Medical University of South Carolina, HSC-17040, Charleston, SC.
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Stelfox HT, Lane D, Boyd JM, Taylor S, Perrier L, Straus S, Zygun D, Zuege DJ. A scoping review of patient discharge from intensive care: opportunities and tools to improve care. Chest 2015; 147:317-327. [PMID: 25210942 DOI: 10.1378/chest.13-2965] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND We conducted a scoping review to systematically review the literature reporting patient discharge from ICUs, identify facilitators and barriers to high-quality care, and describe tools developed to improve care. METHODS We searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Data were extracted on the article type, study details for research articles, patient population, phase of care during discharge, and dimensions of health-care quality. RESULTS From 8,154 unique publications we included 224 articles. Of these, 131 articles (58%) were original research, predominantly case series (23%) and cohort (16%) studies; 12% were narrative reviews; and 11% were guidelines/policies. Common themes included patient and family needs/experiences (29% of articles) and the importance of complete and accurate information (26%). Facilitators of high-quality care included provider-patient communication (30%), provider-provider communication (25%), and the use of guidelines/policies (29%). Patient and family anxiety (21%) and limited availability of ICU and ward resources (26%) were reported barriers to high-quality care. A total of 47 tools to facilitate patient discharge from the ICU were identified and focused on patient evaluation for discharge (29%), discharge planning and teaching (47%), and optimized discharge summaries (23%). CONCLUSIONS Common themes, facilitators and barriers related to patient and family needs/experiences, communication, and the use of guidelines/policies to standardize patient discharge from ICU transcend the literature. Candidate tools to improve care are available; comparative evaluation is needed prior to broad implementation and could be tested through local quality-improvement programs.
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Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Department of Medicine, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, AB; Department of Critical Care Medicine, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, AB.
| | - Dan Lane
- Department of Critical Care Medicine, Department of Medicine, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, AB
| | - Jamie M Boyd
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, AB
| | - Simon Taylor
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, AB
| | - Laure Perrier
- Department of Community Health Sciences, Institute for Public Health, University of Calgary, Calgary, AB; Department of Community Health Sciences, Institute for Public Health, University of Calgary, Calgary, AB; Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto, ON; Department of Continuing Education and Professional Development, University of Toronto, Toronto, ON
| | - Sharon Straus
- Department of Community Health Sciences, Institute for Public Health, University of Calgary, Calgary, AB; Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto, ON; Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto, ON; Department of Medicine Hospital, Saint Michael's University of Toronto, Toronto, ON
| | - David Zygun
- Division of Critical Care, University of Alberta, Edmonton, AB; Department of Critical Care Medicine, Alberta Health Services - Edmonton Zone Edmonton, AB, Canada
| | - Danny J Zuege
- Department of Critical Care Medicine, Department of Medicine, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, AB
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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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Kahn JM, Rubenfeld GD. The myth of the workforce crisis. Why the United States does not need more intensivist physicians. Am J Respir Crit Care Med 2015; 191:128-34. [PMID: 25474081 DOI: 10.1164/rccm.201408-1477cp] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intensivist physician staffing is associated with lower mortality in the intensive care unit (ICU), yet many ICUs are not staffed by trained intensivists. This gap has led to a number of proposals intended to increase the intensivist supply in the United States. In this perspective we argue that such efforts would be both ineffective and ill-advised. Because many ICU patients are not critically ill, workforce models that base demand projections on ICU admission rather than true critical illness substantially overstate the workforce gap. Even in the presence of a workforce gap, training new intensivists would not place them in hospitals where they are needed most, would not mitigate the shortage of nonphysician critical care providers, and would require a unrealistic increase in spending on physician training. In addition, efforts to train more intensivists require us to prioritize intensive care over other specialties that are also in short supply, without clear justification for why intensivists are more important. Rather than continuing an unwarranted push to increase the intensivist supply, we suggest alternative workforce policies that emphasize novel interprofessional care models (to improve ICU quality in the absence of intensivists) combined with limitations on the future growth of ICU beds (to reduce demand through implicit rationing of care). These policies offer opportunities to reduce the mismatch between critical care supply and demand without an unnecessary expansion of the intensivist supply.
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Affiliation(s)
- Jeremy M Kahn
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Training internists to meet critical care needs in the United States: a consensus statement from the Critical Care Societies Collaborative (CCSC). Crit Care Med 2014; 42:1272-9. [PMID: 24637881 PMCID: PMC4165588 DOI: 10.1097/ccm.0000000000000250] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Multiple training pathways are recognized by the Accreditation Council for Graduate Medical Education (ACGME) for internal medicine (IM) physicians to certify in critical care medicine (CCM) via the American Board of Internal Medicine. While each involves 1 year of clinical fellowship training in CCM, substantive differences in training requirements exist among the various pathways. The Critical Care Societies Collaborative convened a task force to review these CCM pathways and to provide recommendations for unified and coordinated training requirements for IM-based physicians. PARTICIPANTS A group of CCM professionals certified in pulmonary-CCM and/or IM-CCM from ACGME-accredited training programs who have expertise in education, administration, research, and clinical practice. DATA SOURCES AND SYNTHESIS Relevant published literature was accessed through a MEDLINE search and references provided by all task force members. Material published by the ACGME, American Board of Internal Medicine, and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force reached consensus using a roundtable meeting, electronic mail, and conference calls. MAIN RESULTS Internal medicine-CCM-based fellowships have disparate program requirements compared to other internal medicine subspecialties and adult CCM fellowships. Differences between IM-CCM and pulmonary-CCM programs include the ratio of key clinical faculty to fellows and a requirement to perform 50 therapeutic bronchoscopies. Competency-based training was considered uniformly desirable for all CCM training pathways. CONCLUSIONS The task force concluded that requesting competency-based training and minimizing variations in the requirements for IM-based CCM fellowship programs will facilitate effective CCM training for both programs and trainees.
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Entropy: A Conceptual Approach to Measuring Situation-level Workload Within Emergency Care and its Relationship to Emergency Department Crowding. J Emerg Med 2014; 46:551-9. [DOI: 10.1016/j.jemermed.2013.08.113] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 08/02/2013] [Accepted: 08/20/2013] [Indexed: 11/22/2022]
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Hua MS, Li G, Blinderman CD, Wunsch H. Estimates of the need for palliative care consultation across united states intensive care units using a trigger-based model. Am J Respir Crit Care Med 2014; 189:428-36. [PMID: 24261961 PMCID: PMC3977718 DOI: 10.1164/rccm.201307-1229oc] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 11/18/2013] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Use of triggers for palliative care consultation has been advocated in intensive care units (ICUs) to ensure appropriate specialist involvement for patients at high risk of unmet palliative care needs. The volume of patients meeting these triggers, and thus the potential workload for providers, is unknown. OBJECTIVES To estimate the prevalence of ICU admissions who met criteria for palliative care consultation using different sets of triggers. METHODS Retrospective cohort study of ICU admissions from Project IMPACT for 2001-2008. We assessed the prevalence of ICU admissions meeting one or more primary palliative care triggers, and prevalence meeting any of multiple sets of triggers. MEASUREMENTS AND MAIN RESULTS Overall, 53,124 (13.8%) ICU admissions met one or more primary triggers for palliative care consultation. Variation in prevalence was minimal across different types of units (mean 13.3% in medical ICUs to 15.8% in trauma/burn ICUs; P = 0.41) and individual units (mean 13.8%, median 13.0%, interquartile range, 10.2-16.5%). A comprehensive model combining multiple sets of triggers identified a total of 75,923 (19.7%) ICU admissions requiring palliative care consultation; of them, 85.4% were captured by five triggers: (1) ICU admission after hospital stay greater than or equal to 10 days, (2) multisystem organ failure greater than or equal to three systems, (3) stage IV malignancy, (4) status post cardiac arrest, and (5) intracerebral hemorrhage requiring mechanical ventilation. CONCLUSIONS Approximately one in seven ICU admissions met triggers for palliative care consultation using a single set of triggers, with an upper estimate of one in five patients using multiple sets of triggers; these estimates were consistent across different types of ICUs and individual units. These results may inform staffing requirements for providers to ensure delivery of specialized palliative care to ICU patients nationally.
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Affiliation(s)
| | - Guohua Li
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, and
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Craig D. Blinderman
- Department of Anesthesiology
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; and
| | - Hannah Wunsch
- Department of Anesthesiology
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, and
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Lofgren ET, Moehring RW, Anderson DJ, Weber DJ, Fefferman NH. A mathematical model to evaluate the routine use of fecal microbiota transplantation to prevent incident and recurrent Clostridium difficile infection. Infect Control Hosp Epidemiol 2013; 35:18-27. [PMID: 24334794 DOI: 10.1086/674394] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Fecal microbiota transplantation (FMT) has been suggested as a new treatment to manage Clostridium difficile infection (CDI). With use of a mathematical model of C. difficile within an intensive care unit (ICU), we examined the potential impact of routine FMT. DESIGN, SETTING, AND PATIENTS A mathematical model of C. difficile transmission, supplemented with prospective cohort, surveillance, and billing data from hospitals in the southeastern United States. METHODS Cohort, surveillance, and billing data as well as data from the literature were used to construct a compartmental model of CDI within an ICU. Patients were defined as being in 1 of 6 potential health states: uncolonized and at low risk; uncolonized and at high risk; colonized and at low risk; colonized and at high risk; having CDI; or treated with FMT. RESULTS The use of FMT to treat patients after CDI was associated with a statistically significant reduction in recurrence but not with a reduction in incident cases. Treatment after administration of high-risk medications, such as antibiotics, did not result in a decrease in recurrence but did result in a statistically significant difference in incident cases across treatment groups, although whether this difference was clinically relevant was questionable. CONCLUSIONS Our study is a novel mathematical model that examines the effect of FMT on the prevention of recurrent and incident CDI. The routine use of FMT represents a promising approach to reduce complex recurrent cases, but a reduction in CDI incidence will require the use of other methods to prevent transmission.
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Affiliation(s)
- Eric T Lofgren
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
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Michtalik HJ, Pronovost PJ, Marsteller JA, Spetz J, Brotman DJ. Identifying potential predictors of a safe attending physician workload: a survey of hospitalists. J Hosp Med 2013; 8:644-6. [PMID: 24124053 PMCID: PMC4087042 DOI: 10.1002/jhm.2088] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 08/19/2013] [Accepted: 08/25/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Henry J. Michtalik
- Department of Medicine, of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Peter J. Pronovost
- Department of Health Policy & Management of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Jill A. Marsteller
- Department of Health Policy & Management of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Joanne Spetz
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Daniel J. Brotman
- Department of Medicine, of the Johns Hopkins University, Baltimore, Maryland, USA
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Joffe AM, Pastores SM, Maerz LL, Mathur P, Lisco SJ. Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors. J Crit Care 2013; 29:112-5. [PMID: 24268625 DOI: 10.1016/j.jcrc.2013.10.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/07/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Non-physician advanced practice providers (APPs) such as nurse practitioners and physician assistants are being increasingly utilized as critical care providers in the United States. The objectives of this study were to determine the utilization of APPs in the intensive care units (ICU)s of academic medical centers (AMCs) and to assess the perceptions of critical care fellowship program directors (PDs) regarding the impact of these APPs on fellowship training. METHODS A cross-sectional national survey questionnaire was distributed to program directors of 331 adult Accreditation Council for Graduate Medical Education-approved critical care fellowship training programs (internal medicine, anesthesiology and surgery) in US AMCs. RESULTS We received 124 (37.5%) PD responses. Of these, 81 (65%) respondents indicated that an APP was part of the care team in either the primary ICU or any ICU in which the fellow trained. The majority of respondents reported that patient care was positively affected by APPs with nearly two-thirds of PDs reporting that fellowship training was also positively impacted. CONCLUSIONS Our survey revealed that APPs are utilized in a large number of US AMCs with critical care training programs. Program director respondents believed that patient care and fellowship training were positively impacted by APPs.
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Affiliation(s)
- Aaron M Joffe
- Department of Anesthesiology & Pain Medicine University of Washington, Harborview Medical Center, Seattle, WA.
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, Weill Cornell Medical College of Cornell University, New York, NY.
| | - Linda L Maerz
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale School of Medicine, New Haven, CT.
| | - Piyush Mathur
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH.
| | - Steven J Lisco
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
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Abstract
The past 50 years have witnessed the emergence and evolution of the modern pediatric ICU and the specialty of pediatric critical care medicine. ICUs have become key in the delivery of health care services. The patient population within pediatric ICUs is diverse. An assortment of providers, including intensivists, trainees, physician assistants, nurse practitioners, and hospitalists, perform a variety of roles. The evolution of critical care medicine also has seen the rise of critical care nursing and other critical care staff collaborating in multidisciplinary teams. Delivery of optimal critical care requires standardized, reliable, and evidence-based processes, such as bundles, checklists, and formalized communication processes.
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Stelfox HT, Perrier L, Straus SE, Ghali WA, Zygun D, Boiteau P, Zuege DJ. Identifying intensive care unit discharge planning tools: protocol for a scoping review. BMJ Open 2013; 3:e002653. [PMID: 23562817 PMCID: PMC3641498 DOI: 10.1136/bmjopen-2013-002653] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 03/07/2013] [Accepted: 03/11/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Transitions of care between providers are vulnerable periods in healthcare delivery that expose patients to preventable errors and adverse events. Patient discharge from the intensive care unit (ICU) to a medical or surgical hospital ward is one of the most challenging and high risk transitions of care. Approximately 1 in 12 patients discharged will be readmitted to ICU or die before leaving the hospital. Many more patients are exposed to unnecessary healthcare, adverse events and/or are disappointed with the quality of their care. Our objective is to conduct a scoping review by systematically searching the literature to identify ICU discharge planning tools and their supporting evidence-base including barriers and facilitators to their use. METHODS AND ANALYSIS Systematic searching of the published health literature will be conducted to identify the existing ICU discharge planning tools and supporting evidence. Literature (research and non-research) reporting on the tools used to facilitate decision making and/or communication at ICU discharge with patients of any age will be included. Outcomes will include adverse events and provider and patient/family-reported outcomes. Two investigators will independently review the abstracts (screen 1) to identify those meeting the inclusion criteria and then independently assess the full text articles (screen 2) to determine if they meet the inclusion criteria. Data collection will include information on citations and identified tools. A quality assessment will be performed on original research studies. A descriptive summary will be developed for each tool. ETHICS AND DISSEMINATION Our scoping review will synthesise the literature for ICU discharge planning tools and identify the opportunities for knowledge to action and gaps in evidence where primary evidence is necessary. This will serve as the foundational element in a multistep research programme to standardise and improve the quality of care provided to patients during ICU discharge. Ethics approval is not required for this study.
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Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
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Blanch L, Annane D, Antonelli M, Chiche JD, Cuñat J, Girard TD, Jiménez EJ, Quintel M, Ugarte S, Mancebo J. The future of intensive care medicine. Med Intensiva 2013; 37:91-8. [PMID: 23398846 DOI: 10.1016/j.medin.2012.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 12/19/2012] [Indexed: 02/04/2023]
Abstract
Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved.
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Affiliation(s)
- L Blanch
- Critical Care Center, Hospital de Sabadell, Corporacio Sanitaria Universitària Parc Taulí, Sabadell, Spain.
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Restricting resident work hours. Crit Care Med 2012. [DOI: 10.1097/ccm.0b013e318256bd6c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Restricting resident work hours. Crit Care Med 2012; 40:2532; author reply 2532-3. [DOI: 10.1097/ccm.0b013e3182536cf9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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