Team working in intensive care: current evidence and future endeavors

A Qualitative Analysis of Observed Behavior of Pediatric Rapid Response Team Performance

BACKGROUND AND OBJECTIVES

Pediatric rapid response teams (RRTs) enhance patient safety, reduce cardiorespiratory arrests outside the PICU, and detect deteriorating patients before decompensation. RRT performance may be affected by failures in communication, poor team dynamics, and poor shared decision-making. We aimed to describe factors associated with team performance using direct observation of pediatric RRTs.

METHODS

Our team directly observed 73 in situ RRT activations, collected field notes of qualitative data, and analyzed the data using conventional content analysis. To assess accuracy of coding, 20% of the coded observations were reassessed for interrater reliability. The codes influencing team performance were categorized as enhancers or threats to RRT teamwork and organized under themes. We constructed a framework of the codes and themes, organized along a spectrum of orderly versus chaotic RRTs.

RESULTS

Three themes influencing RRT performance were teamwork, leadership, and patient and family factors, with underlying codes that enhanced or threatened RRT performance. Novel factors that were found to threaten team performance included indecision, disruptive behavior, changing leadership, and family or patient distress. Our framework delineating features of orderly and chaotic RRTs may be used to inform training and design of RRTs to optimize performance.

CONCLUSIONS

Observations of in situ RRT activations in a pediatric hospital both verified previously described characteristics of RRTs and identified new characteristics of team function. Our proposed framework for understanding these enhancers and threats may be used to inform future interventions to improve RRT performance.

Work team identification associated with less stress and burnout among front-line emergency department staff amid the COVID-19 pandemic

Background

The COVID-19 pandemic has exposed front-line healthcare workers to unprecedented risks and stressors threatening both physical and mental health. Prior work in the military has found that team identification, or the sense that one was a part of a team, can help reduce stress and prevent burnout during prolonged stress.

Methods

We conducted repeated cross-sectional surveys embedded within emergency department workflow to understand whether team identification was associated with reduced reports of stress and burnout among front-line workers.

Results

During the 10-week study which spanned the first wave of COVID-19, 327 of 431 (76%) front-line healthcare workers responded to at least one round of the survey. Higher team identification was associated with significantly less work stress (B=−0.60, 95% CI −0.84 to to -0.40, p<0.001) and burnout (B=−12.87, 95% CI −17.73 to -8.02, p<0.001) in cross-sectional analyses. Further evidence of the protective effect of team identification for work stress (B=−0.36, 95% CI −0.76 to 0.05, p=0.09) and burnout (B=−13.25, 95% CI −17.77 to -8.73, p<0.001) was also found in prospective longitudinal evidence.

Conclusion

This work suggests work team identification is a key buffering factor against feelings of stress and burnout. Efforts to promote team identification may offer a promising way for leaders to support front-line healthcare workers’ well-being during the COVID-19 pandemic. These results can inform ongoing COVID-19 operational and quality improvement initiatives.

Application, verification and correction from an elaborate checklist with some of the recommendations («do and do not do») of the SEMICYUC working groups

OBJECTIVE

Based on some of the recommendations of the SEMICYUC working groups, we developed a checklist and applied it in 2 periods, analyzing their behavior as a tool for improving safety.

DESIGN

A comparative pre- and post-intervention longitudinal study was carried out.

SETTING

The Intensive Care Unit (ICU) of a 400-bed university hospital.

PATIENTS

Random cases series in 2 periods separated by 6 months.

INTERVENTIONS

We developed a checklist with 24 selected indicators that were randomly applied to 50 patients. Verification was conducted by a professional not related to care (prompter). We analyzed the results and compliance index and carried out corrective measures with training. With 6 months of preparation, we again applied the random checklist to 50 patients (post-intervention period) and compared the compliance indexes between the two timepoints.

RESULTS

There were no differences in demographic characteristics or evolution between the periods. The compliance index at baseline was 0.86±0.12 versus 0.91±0.52 in the post-intervention period (P=.023). An acceptable compliance index was obtained with the 24 indicators, though at baseline the compliance index was<0.85 for 5 recommendations. These detected non-compliances were worked upon through training in the second phase of the study. The post-intervention checklist evidenced improvement in compliance with the recommendations.

CONCLUSIONS

The checklist used to assess compliance with a selection of recommendations of the SEMICYUC applied and moderated by a prompter was seen to be a useful instrument allowing us to identify points for improvement in the management of Intensive Care Unit patients, increasing the quality and safety of care.

Does learning from mistakes have to be painful? Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common repetitive reporting errors and suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons

BACKGROUND

The Royal College of Radiologists (RCR) and General Medical Council (GMC) encourage learning from mistakes. But negative feedback can be a demoralising process with adverse implications for staff morale, clinical engagement, team working and perhaps even patient outcomes. We first reviewed the literature regarding positive feedback and teamworking. We wanted to see if we could reconcile our guidance to review and learn from mistakes with evidence that positive interactions had a better effect on teamworking and outcomes than negative interactions. We then aimed to review and categorise the over 600 (mainly discrepancy) cases discussed in our educational cases meeting into educational 'themes'. Finally, we explored whether we could use these educational themes to deliver the same teaching points in a more positive way.

METHODS AND RESULTS

The attendance records, programmes and educational cases from 30 consecutive bimonthly meetings between 2011 and 2017 were prospectively collated and retrospectively analysed. Six hundred and thirty-two cases were collated over the study period where 76% of the cases submitted were discrepancies, or perceived errors. Eight percent were 'good spots' where examples of good calls, excellent reporting, exemplary practice or subtle findings that were successfully reported. Eight percent were educational cases in which no mistake had been made. The remaining 7% included procedural complications or system errors.

CONCLUSION

By analysing the pattern of discrepancies in a department and delivering the teaching in a less negative way, the 'lead' of clinical errors can be turned in to the 'gold' of useful educational tools. Interrogating the whole database periodically can enable a more constructive, wider view of the meeting itself, highlight recurrent deficiencies in practice, and point to where the need for continuing medical training is greatest. Three ways in which our department have utilised this material are outlined: the use of 'good spots', arrangement of targeted teaching and production of specialist educational material. These techniques can all contribute to a more positive learning experience with the emphasis on acknowledging and celebrating excellence (ACE).

Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: a grounded theory study

BACKGROUND

Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context.

METHODS

The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data.

RESULTS

A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational.

CONCLUSIONS

The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.

Variables associated with work performance in multidisciplinary mental health teams

OBJECTIVES

This study investigates work performance among 79 mental health teams in Quebec (Canada). We hypothesized that work performance was positively associated with the use of standardized clinical tools and clinical approaches, integration strategies, "clan culture," and mental health funding per capita.

METHODS

Work performance was measured using an adapted version of the Work Role Questionnaire. Variables were organized into four key areas: (1) team attributes, (2) organizational culture, (3) inter-organizational interactions, and (4) external environment.

RESULTS

Work performance was associated with two types of organizational culture (clan and hierarchy) and with two team attributes (use of standardized clinical tools and approaches).

DISCUSSION AND CONCLUSION

This study was innovative in identifying associations between work performance and best practices, justifying their implementation. Recommendations are provided to develop organizational cultures promoting a greater focus on the external environment and integration strategies that strengthen external focus, service effectiveness, and innovation.

Assessing archetypes of organizational culture based on the Competing Values Framework: the experimental use of the framework in Japanese neonatal intensive care units

Objective

To assess organizational culture in neonatal intensive care units (NICUs) in Japan.

Design

Cross-sectional survey of organizational culture.

Setting

Forty NICUs across Japan.

Participants

Physicians and nurses who worked in NICUs (n = 2006).

Main Outcome Measures

The Competing Values Framework (CVF) was used to assess the organizational culture of the study population. The 20-item CVF was divided into four culture archetypes: Group, Developmental, Hierarchical and Rational. We calculated geometric means (gmean) and 95% bootstrap confidence intervals of the individual dimensions by unit and occupation. The median number of staff, beds, physicians’ work hours and work engagement were also calculated to examine the differences by culture archetypes.

Results

Group (gmean = 34.6) and Hierarchical (gmean = 31.7) culture archetypes were higher than Developmental (gmean = 16.3) and Rational (gmean = 17.4) among physicians as a whole. Hierarchical (gmean = 36.3) was the highest followed by Group (gmean = 25.8), Developmental (gmean = 16.3) and Rational (gmean = 21.7) among nurses as a whole. Units with dominant Hierarchical culture had a slightly higher number of physicians (median = 7) than dominant Group culture (median = 6). Units with dominant Group culture had a higher number of beds (median = 12) than dominant Hierarchical culture (median = 9) among physicians. Nurses from units with a dominant Group culture (median = 2.8) had slightly higher work engagement compared with those in units with a dominant Hierarchical culture (median = 2.6).

Conclusions

Our findings revealed that organizational culture in NICUs varies depending on occupation and group size. Group and Hierarchical cultures predominated in Japanese NICUs. Assessing organizational culture will provide insights into the perceptions of unit values to improve quality of care.

Real-time random safety audits: A transforming tool adapted to new times

Real-time random safety audits constitute a tool designed to transfer knowledge from the sources of scientific evidence to the patient bedside. It has proven useful in critically ill patients, improving safety in the process of critical patient care, turning unsafe situations into safe ones in daily practice, and ensuring adherence to scientific evidence. In parallel, the design and methodology involved affords process indicators that will make it possible to know how we provide care for our patients, evolution over time (with regular feedback for professionals), the impact of our interventions, and benchmarking.

Team Cognition As a Means to Improve Care Delivery in Critically Ill Patients With Cancer After Hematopoietic Cell Transplantation

Hematopoietic cell transplantation (HCT) is an important and complex treatment modality for a variety of hematologic malignancies and some solid tumors. Although outcomes of patients who have undergone HCT and require care in intensive care units (ICUs) have improved over time, mortality rates remain high and there are significant associated costs. Lack of a team-based approach to care, especially during critical illness, is detrimental to patient autonomy and satisfaction, and to team morale, ultimately leading to poor quality of care. In this manuscript, we describe the case of a patient who had undergone HCT and was in the ICU setting, where inconsistent team interaction among the various stakeholders delivering care resulted in a lack of shared goals and poor outcomes. Team cognition is cognitive processing at the team level through interactions among team members and is reflected in dynamic communication and coordination behaviors. Although the patient received multidisciplinary care as needed in a medically complicated case, a lack of team cognition and, particularly, inconsistent communication among the dynamic teams caring for the patient, led to mixed messages being delivered with high-cost implications for the health-care system and the family. This article highlights concepts and recommendations that begin a necessary in-depth assessment of implications for clinical care and initiate a research agenda that examines the effects of team cognition on HCT teams, and, more generally, critical care of the patient with cancer.

Optimizing Team Dynamics: An Assessment of Physician Trainees and Advanced Practice Providers Collaborative Practice

OBJECTIVES

The presence of advanced practice providers has become increasingly common in many ICUs. The ideal staffing model for units that contain both advanced practice providers and physician trainees has not been described. The objectives of this study were to evaluate ICU staffing models that include physician trainees and advanced practice providers and their effects on patient outcomes, resident and fellow education, and training experience. A second aim was to assess strategies to promote collaboration between team members.

DATA SOURCES

PubMed, CINAHL, OVID MEDLINE, and Cochrane Review from 2002 to 2015.

STUDY SELECTION

Experimental study designs conducted in an ICU setting.

DATA EXTRACTION

Two reviewers screened articles for eligibility and independently abstracted data using the identified search terms.

DATA SYNTHESIS

We found 21 articles describing ICU team structure and outcomes. Four articles were found describing the impact of advanced practice providers on resident or fellow education. Two articles were found discussing strategies to promote collaboration between advanced practice providers and critical care fellows or residents.

CONCLUSIONS

Several articles were identified describing the utilization of advanced practice providers in the ICU and the impact of models of care on patient outcomes. Limited data exist describing the impact of advanced practice providers on resident and fellow education and training experience. In addition, there are minimal data describing methods to enhance collaboration between providers. Future research should focus on determining the optimal ICU team structure to improve patient outcomes, education of trainees, and job satisfaction of team members and methods to promote collaboration between advanced practice providers and physicians in training.

Communication and Culture in the Surgical Intensive Care Unit: Boundary Production and the Improvement of Patient Care

This ethnography explores communication around critically ill surgical patients in three surgical intensive care units (ICUs) in Canada. A boundary framework is used to articulate how surgeons', intensivists', and nurses' communication practices shape and are shaped by their respective disciplinary perspectives and experiences. Through 50 hours of observations and 43 interviews, these health care providers are found to engage in seven communication behaviors that either mitigate or magnify three contested symbolic boundaries: expertise, patient ownership, and decisional authority. Where these boundaries are successfully mitigated, experiences of collaborative, high-quality patient care are produced; by contrast, boundary magnification produces conflict and perceptions of unsafe patient care. Findings reveal that high quality and safe patient care are produced through complex social and cultural interactions among surgeons, intensivists, and nurses that are also expressions of knowledge and power. This enhances our understanding of why current quality improvement efforts targeting communication may be ineffective.

Impact of procedural justice perception on team commitment

Purpose

– The purpose of this paper is to understand the impact of procedural justice on team members’ commitment and the role of task routineness and participatory safety in this relationship.

Design/methodology/approach

– Survey method was used to collect data from 177 respondents from 33 software development teams. Participatory Safety Scale from Anderson and West’s Team Climate Inventory, Colquitt’s Procedural Justice Scale, a modified version of Mowday et al.’s Organizational Commitment Scale and Daft and Macintosh’s Task Routineness Scale were used to measure the variables studied. Regression analysis was used to test the main, mediating and moderating effects.

Findings

– Results showed a significant positive impact of procedural justice perception on participatory safety dimensions and team commitment. Task routineness did not show any significant moderation effect. Perception of participatory safety had a partial mediation effect.

Research limitations/implications

– A relatively smaller sample size, purposive sampling technique and absence of relevant control variables are the key limitations of this study.

Practical implications

– The findings will provide managers insights on designing the team tasks and procedures to nurture participatory safety and commitment in teams.

Originality/value

– The study is unique in terms of selection of variables, design (moderation and mediating effects) and the context (software development teams). The study provides a holistic picture of team dynamics by studying variables related to procedures, task and psychological states of the individual.

Measurement properties and implementation of a checklist to assess leadership skills during interdisciplinary rounds in the intensive care unit

The implementation of interdisciplinary teams in the intensive care unit (ICU) has focused attention on leadership behavior. A daily recurrent situation in ICUs in which both leadership behavior and interdisciplinary teamwork are integrated concerns the interdisciplinary rounds (IDRs). Although IDRs are recommended to provide optimal interdisciplinary and patient-centered care, there are no checklists available for leading physicians. We tested the measurement properties and implementation of a checklist to assess the quality of leadership skills in interdisciplinary rounds. The measurement properties of the checklist, which included 10 essential quality indicators, were tested for interrater reliability and internal consistency and by factor analysis. The interrater reliability among 3 raters was good (κ, 0.85) and the internal consistency was acceptable (α, 0.74). Factor analysis showed all factor loadings on 1 domain (>0.65). The checklist was further implemented during videotaped IDRs which were led by senior physicians and in which 99 patients were discussed. Implementation of the checklist showed a wide range of "no" and "yes" scores among the senior physicians. These results may underline the need for such a checklist to ensure tasks are synchronized within the team.

Time to look beyond one-year mortality in critically ill hematological patients?

The spectacular improvement in long-term prognosis of patients with hematological malignancies since the 1980s, coupled with the subsequent improvement over the past decade in short- and mid-term survival in cases of critical illness, resulted in an increasing referral of such patients to the ICU. A remaining question, however, is how these patients perform in the long term with regard to survival and quality of life. Here we discuss the present multicenter study on survival beyond 1 year in critically ill patients with hematological malignancies. We conclude with suggestions on how we can further improve the long-term outcome of these patients.

'Safety by DEFAULT': introduction and impact of a paediatric ward round checklist

Introduction

Poor communication is a source of risk. This can be particularly significant in areas of high clinical acuity such as intensive care. Ward rounds are points where large amounts of information must be communicated in a time-limited environment with many competing interests. This has the potential to reduce effective communication and risk patient safety. Checklists have been used in many industries to improve communication and mitigate risk. We describe the introduction of a ward round safety checklist ‘DEFAULT’ on a paediatric intensive care unit.

Methods

A non-blinded, pre- and post-intervention observational study was undertaken in a 12-bedded Level 3 tertiary PICU between July 2009 and December 2011.

Results

Ward round stakeholders subjectively liked the checklist and felt it improved communication. Introduction of the ward round checklist was associated with an increase in median days between accidental extubations from 14 (range 2 to 86) to 150 (56 to 365) (Mann–Whitney P <0.0001). The ward round checklist was also associated with an increase in the proportion of invasively ventilated patients with target tidal volumes of <8 ml/kg, which increased from 35 of 71 patients at 08.00 representing a proportion of 0.49 (95% CI 0.38 to 0.60) to 23 of 38 (0.61, 0.45 to 0.74). This represented a trend towards an increased proportion of cases in the target range (z = 1.68, P = 0.09).

Conclusions

The introduction of a ward round safety checklist was associated with improved communication and patient safety.

Illusions of team working in health care

PURPOSE

The ubiquity and value of teams in healthcare are well acknowledged. However, in practice, healthcare teams vary dramatically in their structures and effectiveness in ways that can damage team processes and patient outcomes. The aim of this paper is to highlight these characteristics and to extrapolate several important aspects of teamwork that have a powerful impact on team effectiveness across healthcare contexts.

DESIGN/METHODOLOGY/APPROACH

The paper draws upon the literature from health services management and organisational behaviour to provide an overview of the current science of healthcare teams.

FINDINGS

Underpinned by the input-process-output framework of team effectiveness, team composition, team task, and organisational support are viewed as critical inputs that influence key team processes including team objectives, leadership and reflexivity, which in turn impact staff and patient outcomes. Team training interventions and care pathways can facilitate more effective interdisciplinary teamwork.

ORIGINALITY/VALUE

The paper argues that the prevalence of the term "team" in healthcare makes the synthesis and advancement of the scientific understanding of healthcare teams a challenge. Future research therefore needs to better define the fundamental characteristics of teams in studies in order to ensure that findings based on real teams, rather than pseudo-like groups, are accumulated.

An overview of end-of-life issues in the intensive care unit

The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.

The relationship between organizational culture and family satisfaction in critical care

OBJECTIVES

Family satisfaction with critical care is influenced by a variety of factors. We investigated the relationship between measures of organizational and safety culture, and family satisfaction in critical care. We further explored differences in this relationship depending on intensive care unit survival status and length of intensive care unit stay of the patient.

DESIGN

Cross-sectional surveys.

SETTING

Twenty-three tertiary and community intensive care units within three provinces in Canada.

SUBJECTS

One thousand two-hundred eighty-five respondents from 2374 intensive care unit clinical staff, and 880 respondents from 1381 family members of intensive care unit patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Intensive care unit staff completed the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture. Family members completed the Family Satisfaction in the Intensive Care Unit 24, a validated survey of family satisfaction. A priori, we analyzed adjusted relationships between each domain score from the culture surveys and either satisfaction with care or satisfaction with decision-making for each of four subgroups of family members according to patient descriptors: intensive care unit survivors who had length of intensive care unit stay <14 days or >14 days, and intensive care unit nonsurvivors who had length of stay <14 days or ≥14 days. We found strong positive relationships between most domains of organizational and safety culture, and satisfaction with care or decision-making for family members of intensive care unit nonsurvivors who spent at least 14 days in the intensive care unit. For the other three groups, there were only a few weak relationships between domains of organizational and safety culture and family satisfaction.

CONCLUSIONS

Our findings suggest that the effect of organizational culture on care delivery is most easily detectable by family members of the most seriously ill patients who interact frequently with intensive care unit staff, who are intensive care unit nonsurvivors, and who spend a longer time in the intensive care unit. Positive relationships between measures of organizational and safety culture and family satisfaction suggest that by improving organizational culture, we may also improve family satisfaction.