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Karwa ML, Naqvi AA, Betchen M, Puri AK. In-Hospital Triage. Crit Care Clin 2024; 40:533-548. [PMID: 38796226 DOI: 10.1016/j.ccc.2024.03.001] [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: 05/28/2024]
Abstract
The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.
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Affiliation(s)
- Manoj L Karwa
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Weiler Hospital, 4th Floor, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Ali Abbas Naqvi
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Melanie Betchen
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Ajay Kumar Puri
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
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Barker AK, Valley TS, Kenes MT, Sjoding MW. Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study. Chest 2024; 166:118-126. [PMID: 38218219 PMCID: PMC11317814 DOI: 10.1016/j.chest.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/02/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19. RESEARCH QUESTION Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19? STUDY DESIGN AND METHODS We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods. RESULTS In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period. INTERPRETATION We found that among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.
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Affiliation(s)
- Anna K Barker
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI.
| | - Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | | | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
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Dave YA, Temple LKF, Juviler PG, Nabozny MJ, Cvetanovska M, Wakeman D, Cannon LM. Think Twice: De-implementation of Laboratory Testing After Colorectal Surgery. Dis Colon Rectum 2024; 67:587-595. [PMID: 38108409 DOI: 10.1097/dcr.0000000000003156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
BACKGROUND Clinically unindicated laboratory testing contributes to low-value care. Most postoperative day 1 laboratory tests after colorectal surgery are normal. However, no published interventions have shown that reducing overall postoperative laboratory testing is safe. OBJECTIVE This study aimed to investigate the impact of reducing postoperative laboratory testing after colorectal surgery. DESIGN This is a quality improvement study. SETTINGS The study was conducted at an academic center with an enhanced recovery after surgery program that included 5 daily laboratory tests until discharge. PATIENTS All adults undergoing colorectal or small-bowel surgery formed intervention and nonintervention cohorts based on surgeons who chose to opt into the study. Preimplementation (November 2019-October 2021), there were 545 intervention and 577 nonintervention patients. Postimplementation (November 2021-March 2023), there were 448 intervention and 437 nonintervention patients. INTERVENTIONS The intervention included 3 postoperative day 1 laboratory tests and subsequent clinically indicated laboratory tests. MAIN OUTCOME MEASURES Outcome measures included laboratory tests and days free of laboratory work. RESULTS Postintervention, the intervention group had a 33% reduction in laboratory tests per hospital stay, a 26% reduction in laboratory tests per day, and a 49% increase in laboratory test-free days. There was no difference in length of stay (4 vs 4; p = 0.79) or readmissions (14.9% vs 12.9%; p = 0.39). The nonintervention group had no significant changes in laboratory work or laboratory test-free days, with no differences in length of stay (4 vs 4; p = 0.49) or readmissions (11.1% vs 11.0%; p = 0.96). LIMITATIONS Demographics and complication rates were not reported. CONCLUSIONS An intervention targeting reflexive laboratory testing after colorectal surgery resulted in safe, significant, sustained reductions in postoperative laboratory work, with substantial cost savings. These findings prompted a change in the laboratory order set to an opt-out system, and laboratory work reduction approaches have been implemented within other surgical divisions. Continuation and spread of these efforts are instrumental for prioritization of high-value surgical care. See Video Abstract . PINSELO DOS VECES ELIMINACIN DE LAS PRUEBAS DE LABORATORIO DESPUS DE LA CIRUGA COLORRECTAL ANTECEDENTES:Las pruebas de laboratorio clínicamente no indicadas contribuyen a una atención de bajo valor. La mayoría de los análisis de laboratorio del primer día post operatorios de una cirugía colorrectal son normales. Sin embargo, ninguna intervención publicada ha demostrado que reducir las pruebas de laboratorio post operatorias generales sea seguro.OBJETIVO:El objetivo de este estudio fue investigar el impacto de reducir las pruebas de laboratorio pos toperatorias después de la cirugía colorrectal.DISEÑO:Este es un estudio de mejora de la calidad.AJUSTES:El estudio se llevó a cabo en un centro académico con un programa mejorado de recuperación después de la cirugía que incluye 5 laboratorios diarios hasta el alta.PACIENTES:Todos los adultos sometidos a cirugía colorrectal o de intestino delgado formaron cohortes de intervención y no intervención basadas en los cirujanos que optaron por participar en el estudio. Antes de la implementación (noviembre de 2019 - octubre de 2021) había 545 pacientes con intervención y 577 sin intervención. Después de la implementación (noviembre de 2021 - marzo de 2023) hubo 448 pacientes con intervención y 437 sin intervención.INTERVENCIONES:La intervención incluyó 3 laboratorios post operatorios del primer día y laboratorios posteriores clínicamente indicados.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron pruebas de laboratorio y días sin laboratorio.RESULTADOS:Después de la intervención, el grupo de intervención tuvo una reducción del 33 % en laboratorios por estancia hospitalaria, una reducción del 26 % en laboratorios por día y un aumento del 49 % en los días sin laboratorio. No hubo diferencias en la duración de la estancia hospitalaria (4 frente a 4; p = 0,79) ni en los reingresos (14,9% frente a 12,9%; p = 0,39). El grupo de no intervención no tuvo cambios significativos en el trabajo de laboratorio o en los días sin laboratorio, sin diferencias en la duración de la estadía (4 versus 4; p = 0,49) o reingresos (11,1% versus 11,0%; p = 0,96).LIMITACIONES:No se informaron datos demográficos ni tasa de complicaciones.CONCLUSIONES:Una intervención dirigida a pruebas de laboratorio reflexivas después de la cirugía colorrectal resultó en reducciones seguras, significativas y sostenidas en el trabajo de laboratorio post operatorio, con ahorros sustanciales de costos. Estos hallazgos provocaron un cambio en el orden del laboratorio establecido hacia un sistema de exclusión voluntaria, y se han implementado enfoques de reducción del trabajo de laboratorio en otras divisiones quirúrgicas. La continuación y difusión de estos esfuerzos son fundamentales para priorizar la atención quirúrgica de alto valor. (Traducción-Dr. Mauricio Santamaria ).
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Affiliation(s)
- Yatee A Dave
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
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Courtright KR, Madden V, Bayes B, Chowdhury M, Whitman C, Small DS, Harhay MO, Parra S, Cooney-Zingman E, Ersek M, Escobar GJ, Hill SH, Halpern SD. Default Palliative Care Consultation for Seriously Ill Hospitalized Patients: A Pragmatic Cluster Randomized Trial. JAMA 2024; 331:224-232. [PMID: 38227032 PMCID: PMC10792472 DOI: 10.1001/jama.2023.25092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/14/2023] [Indexed: 01/17/2024]
Abstract
Importance Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking. Objective To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and improved outcomes. Design, Setting, and Participants A pragmatic, stepped-wedge, cluster randomized trial was conducted among patients 65 years or older with advanced chronic obstructive pulmonary disease, dementia, or kidney failure admitted from March 21, 2016, through November 14, 2018, to 11 US hospitals. Outcome data collection ended on January 31, 2019. Intervention Ordering palliative care consultation by default for eligible patients, while allowing clinicians to opt-out, was compared with usual care, in which clinicians could choose to order palliative care. Main Outcomes and Measures The primary outcome was hospital length of stay, with deaths coded as the longest length of stay, and secondary end points included palliative care consult rate, discharge to hospice, do-not-resuscitate orders, and in-hospital mortality. Results Of 34 239 patients enrolled, 24 065 had lengths of stay of at least 72 hours and were included in the primary analytic sample (10 313 in the default order group and 13 752 in the usual care group; 13 338 [55.4%] women; mean age, 77.9 years). A higher percentage of patients in the default order group received palliative care consultation than in the standard care group (43.9% vs 16.6%; adjusted odds ratio [aOR], 5.17 [95% CI, 4.59-5.81]) and received consultation earlier (mean [SD] of 3.4 [2.6] days after admission vs 4.6 [4.8] days; P < .001). Length of stay did not differ between the default order and usual care groups (percent difference in median length of stay, -0.53% [95% CI, -3.51% to 2.53%]). Patients in the default order group had higher rates of do-not-resuscitate orders at discharge (aOR, 1.40 [95% CI, 1.21-1.63]) and discharge to hospice (aOR, 1.30 [95% CI, 1.07-1.57]) than the usual care group, and similar in-hospital mortality (4.7% vs 4.2%; aOR, 0.86 [95% CI, 0.68-1.08]). Conclusions and Relevance Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes. Trial Registration ClinicalTrials.gov Identifier: NCT02505035.
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Affiliation(s)
- Katherine R. Courtright
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Vanessa Madden
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
| | - Casey Whitman
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
| | - Dylan S. Small
- Department of Statistics, Wharton School, University of Pennsylvania, Philadelphia
| | - Michael O. Harhay
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | | | - Elizabeth Cooney-Zingman
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Mary Ersek
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia
| | | | | | - Scott D. Halpern
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
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Bass GA, Chang CWJ, Sorce LR, Subramanian S, Laytin AD, Somodi R, Gray JR, Lane-Fall M, Kaplan LJ. Gamification in Critical Care Education and Practice. Crit Care Explor 2024; 6:e1034. [PMID: 38259864 PMCID: PMC10803028 DOI: 10.1097/cce.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVES To explore gamification as an alternative approach to healthcare education and its potential applications to critical care. DATA SOURCES English language manuscripts addressing: 1) gamification theory and application in healthcare and critical care and 2) implementation science focused on the knowledge-to-practice gap were identified in Medline and PubMed databases (inception to 2023). STUDY SELECTION Studies delineating gamification underpinnings, application in education or procedural mentoring, utilization for healthcare or critical care education and practice, and analyses of benefits or pitfalls in comparison to other educational or behavioral modification approaches. DATA EXTRACTION Data indicated the key gamification tenets and the venues within which they were used to enhance knowledge, support continuing medical education, teach procedural skills, enhance decision-making, or modify behavior. DATA SYNTHESIS Gamification engages learners in a visual and cognitive fashion using competitive approaches to enhance acquiring new knowledge or skills. While gamification may be used in a variety of settings, specific design elements may relate to the learning environment or learner styles. Additionally, solo and group gamification approaches demonstrate success and leverage adult learning theory elements in a low-stress and low-risk setting. The potential for gamification-driven behavioral modification to close the knowledge-to-practice gap and enable guideline and protocol compliance remains underutilized. CONCLUSIONS Gamification offers the potential to substantially enhance how critical care professionals acquire and then implement new knowledge in a fashion that is more engaging and rewarding than traditional approaches. Accordingly, educational undertakings from courses to offerings at medical professional meetings may benefit from being gamified.
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Affiliation(s)
- Gary Alan Bass
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Lauren R Sorce
- Department of Pediatrics (Critical Care), Northwestern University, Chicago, IL
| | - Sanjay Subramanian
- Department of Anesthesiology, Critical Care Medicine, Washington University in St. Louis, St. Louis, MO
- Omnicure Inc., St. Louis, MO
| | - Adam D Laytin
- Departments of Anesthesia and Critical Care Medicine and Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Reka Somodi
- Section of Surgical Critical Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Jaime R Gray
- Department of Pharmacy, Temple University Health System, Philadelphia, PA
| | - Meghan Lane-Fall
- Departments of Anesthesiology and Critical Care Medicine and Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Kansal A, Latour JM, See KC, Rai S, Cecconi M, Britto C, Conway Morris A, Dominic Savio R, Nadkarni VM, Rao BK, Mishra R. Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study. Crit Care 2023; 27:487. [PMID: 38082302 PMCID: PMC10712165 DOI: 10.1186/s13054-023-04766-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources. METHODS A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice. RESULTS At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept. CONCLUSIONS This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.
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Affiliation(s)
- Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Jurong Health Campus, National University Health System, Singapore, Singapore.
| | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sumeet Rai
- Intensive Care Unit, Canberra Hospital, Canberra, Australia
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Carl Britto
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, USA
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics at the Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - B K Rao
- Department of Critical Care Medicine, Sir Ganga Ram Hospital, New Delhi, India
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Sznol JA, Becher R, Maung AA, Bhattacharya B, Davis K, Schuster KM. Routine post-operative labs and healthcare system burden in acute appendicitis. Am J Surg 2023; 226:571-577. [PMID: 37291012 DOI: 10.1016/j.amjsurg.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/16/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Data from the National Health Expenditure Accounts have shown a steady increase in healthcare cost paralleled by availability of laboratory tests. Resource utilization is a top priority for reducing health care costs. We hypothesized that routine post-operative laboratory utilization unnecessarily increases costs and healthcare system burden in acute appendicitis (AA) management. METHODS A retrospective cohort of patients with uncomplicated AA 2016-2020 were identified. Clinical variables, demographics, lab usage, interventions, and costs were collected. RESULTS A total of 3711 patients with uncomplicated AA were identified. Total costs of labs ($289,505, 99.56%) and repletions ($1287.63, 0.44%) were $290,792.63. Increased LOS was associated with lab utilization in multivariable modeling, increasing costs by $837,602 or 472.12 per patient. CONCLUSIONS In our patient population, post-operative labs resulted in increased costs without discernible impact on clinical course. Routine post-operative laboratory testing should be re-evaluated in patients with minimal comorbidities as this likely increases cost without adding value.
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Affiliation(s)
- Joshua A Sznol
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Robert Becher
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Adrian A Maung
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Bishwajit Bhattacharya
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kimberly Davis
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kevin M Schuster
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
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Dziorny A, Jones C, Salant J, Kubis S, Zand MS, Wolfe H, Srinivasan V. Clinical and Analytic Accuracy of Simultaneously Acquired Hemoglobin Measurements: A Multi-Institution Cohort Study to Minimize Redundant Laboratory Usage. Pediatr Crit Care Med 2023; 24:e520-e530. [PMID: 37219964 PMCID: PMC10665541 DOI: 10.1097/pcc.0000000000003287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Frequent diagnostic blood sampling contributes to anemia among critically ill children. Reducing duplicative hemoglobin testing while maintaining clinical accuracy can improve patient care efficacy. The objective of this study was to determine the analytical and clinical accuracy of simultaneously acquired hemoglobin measurements with different methods. DESIGN Retrospective cohort study. SETTING Two U.S. children's hospitals. PATIENTS Children (< 18 yr old) admitted to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified hemoglobin results from complete blood count (CBC) panels paired with blood gas (BG) panels and point-of-care (POC) devices. We estimated analytic accuracy by comparing hemoglobin distributions, correlation coefficients, and Bland-Altman bias. We measured clinical accuracy with error grid analysis and defined mismatch zones as low, medium, or high risk-based on deviance from unity and risk of therapeutic error. We calculated pairwise agreement to a binary decision to transfuse based on a hemoglobin value. Our cohort includes 49,004 ICU admissions from 29,926 patients, resulting in 85,757 CBC-BG hemoglobin pairs. BG hemoglobin was significantly higher (mean bias, 0.43-0.58 g/dL) than CBC hemoglobin with similar Pearson correlation ( R2 ) (0.90-0.91). POC hemoglobin was also significantly higher, but of lower magnitude (mean bias, 0.14 g/dL). Error grid analysis revealed only 78 (< 0.1%) CBC-BG hemoglobin pairs in the high-risk zone. For CBC-BG hemoglobin pairs, at a BG hemoglobin cutoff of greater than 8.0 g/dL, the "number needed to miss" a CBC hemoglobin less than 7 g/dL was 275 and 474 at each institution, respectively. CONCLUSIONS In this pragmatic two-institution cohort of greater than 29,000 patients, we show similar clinical and analytic accuracy of CBC and BG hemoglobin. Although BG hemoglobin values are higher than CBC hemoglobin values, the small magnitude is unlikely to be clinically significant. Application of these findings may reduce duplicative testing and decrease anemia among critically ill children.
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Affiliation(s)
- Adam Dziorny
- Department of Pediatrics, University of Rochester School of
Medicine, Rochester, NY
- Department of Biomedical Engineering, University of
Rochester, Rochester, NY
| | - Chloe Jones
- Department of Biomedical Engineering, University of
Rochester, Rochester, NY
| | - Jennifer Salant
- Department of Pediatrics, Weill Cornell Medicine, New York,
NY
| | - Sherri Kubis
- Department of Anesthesiology & Critical Care Medicine,
Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Martin S. Zand
- Department of Internal Medicine, University of Rochester
School of Medicine, Rochester NY
| | - Heather Wolfe
- Department of Anesthesiology & Critical Care Medicine,
Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care and Pediatrics,
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Vijay Srinivasan
- Department of Anesthesiology & Critical Care Medicine,
Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care and Pediatrics,
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Vargas M, Buonanno P, De Simone S, Russo G, Iacovazzo C, Servillo G. Trends for Percutaneous Tracheostomy in Italian Acute Care Setting over a 5-Year Period. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1444. [PMID: 37629734 PMCID: PMC10456237 DOI: 10.3390/medicina59081444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/30/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
Background: Tracheostomy is a widespread procedure usually performed with a percutaneous approach for prolonged mechanical ventilation. Little is known about the population-based trends for percutaneous tracheostomies (PT). The aim of this study was to evaluate the order to analyze the characteristics, rates, and costs of PTs performed in Italy from 2009 to 2014. Methods: We analyzed 102,646 PTs performed in Italy between 2009 and 2014. We obtained the data of patients from the section of the discharge report of the Italian Ministry of Health (National Archive for Hospital Discharge Form, Ministry of Health) about age, gender, length of stay (LOS), hospital types, and hospital region for code 541 and 542 for the years 2009, 2010, 2011, 2012, 2013 and 2014. Our additional source of data was the Annual Discharge Reports of the Italian Ministry of Health. Results: In this study, including 102,646 PTs performed from 2009 to 2014, we found that (1) the rates of PTs significantly decreased over time; (2) PTs were mostly performed in patients aged less than 65 years and hospitalized in ICUs for less than 40 days; and (3) the costs of PTs severely decreased over time, with a breakpoint between 2011 and 2012. Conclusions: Percutaneous tracheostomy is still a procedure frequently performed in the setting of acute care. Although percutaneous tracheostomy still results in high medical care reimbursement, it is a safe and cost-saving procedure.
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Affiliation(s)
- Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80138 Naples, Italy
| | - Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80138 Naples, Italy
| | - Stefania De Simone
- Department of Political Sciences, University of Naples Federico II, 80138 Naples, Italy
| | - Gennaro Russo
- Otolaryngology Head and Neck Surgery Unit, “Azienda Ospedaliera di Rilievo Nazionale dei Colli, Ospedale Monaldi”, 80138 Naples, Italy
| | - Carmine Iacovazzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80138 Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80138 Naples, Italy
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10
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Hjortsø CJS, Møller MH, Perner A, Brøchner AC. Routine Versus On-Demand Blood Sampling in Critically Ill Patients: A Systematic Review. Crit Care Med 2023; 51:717-730. [PMID: 36951465 DOI: 10.1097/ccm.0000000000005852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVES We aimed to provide an overview of the current evidence on routine versus on-demand blood sampling in critical care. We assessed the reported proportion of patients exposed to daily routine blood sampling, the tests performed, characteristics associated with more frequent blood sampling, and the reported benefits and harms of routine blood sampling compared with on-demand sampling. DATA SOURCES We systematically searched the Cochrane Library, the Excerpta Medica Database, and the Medical Literature Analysis and Retrieval System Online for studies assessing routine versus on-demand blood testing in critically ill patients from inception to September 2022. STUDY SELECTION Abstracts and full texts were assessed independently and in duplicate by two reviewers. STUDY EXTRACTION Data were extracted independently and in duplicate by two reviewers using predefined extraction forms. DATA SYNTHESIS Of 12,212 records screened, 298 full-text articles were assessed for eligibility. We included 70 studies; 50 nonrandomized interventional studies and 20 observational studies. Exposure to routine blood testing was 52-100% (very low certainty of evidence). Blood testing seemed to occur more frequently in medical intensive care settings with a median of 18 blood tests per patient day (interquartile range, 10-33) (very low certainty of evidence). Mixed biochemistry seemed to be the most frequently performed blood tests across all settings (five tests per patient day; interquartile range, 2-10) (very low certainty of evidence). Reductions in routine blood testing seemed to be associated with reduced transfusion rates and costs without apparent adverse patient outcomes (low certainty of evidence). CONCLUSIONS In this systematic review, routine blood testing in critically ill patients was common and varied considerably. A reduction in routine blood testing appeared to be associated with reduced transfusion rates and costs without adverse effects, but the evidence was very uncertain.
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Affiliation(s)
- Carl J S Hjortsø
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne C Brøchner
- Department of Intensive Care, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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11
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Duan X, Shao W, Jiang W, Tan X, Zhu J, Yang J, Zhao Y, Zhang C, Yu Q, Yang Y, Zhou J, Pan B, Wang B, Guo W. Status of phlebotomy tube utilization at a major medical center. Are we using too many phlebotomy tubes? Heliyon 2023; 9:e15334. [PMID: 37131426 PMCID: PMC10149253 DOI: 10.1016/j.heliyon.2023.e15334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 05/04/2023] Open
Abstract
Background and objectives Overutilization of phlebotomy tubes at healthcare facilities leads to iatrogenic anemia, patient dissatisfaction, and increase in operational costs. In this study, we analyzed the phlebotomy tube usage data at the Zhongshan Hospital, Fudan University, to show potential inefficiencies with phlebotomy tube usage. Methods Data of 984,078 patients with 1,408,175 orders and 4,622,349 total phlebotomy tubes were collected during years 2018-2021. Data of different patient types were compared. Furthermore, we assessed the data from subspecialty and test levels to explore the factors influencing the increase in phlebotomy tube usage. Results We observed an overall 8% increase in both the mean number of tubes used and blood loss per order over the past 4 years. The mean blood loss per day for intensive care unit (ICU) patients was 18.7 ml (maximum 121.6 ml), which was well under the 200 ml/day threshold. However, the maximum number of tubes used reached more than 30 tubes/day. Conclusions The 8% increase of phlebotomy tubes over 4 years should alarm laboratory managements, as tests offered are expected to increase in the future. Importantly, the whole healthcare community needs to work together to solve this problem with more creative solutions.
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Affiliation(s)
- Xincen Duan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenqi Shao
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhai Jiang
- IT Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao Tan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Zhu
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Yang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yin Zhao
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunyan Zhang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qian Yu
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yihui Yang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaye Zhou
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Baishen Pan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Corresponding author. Clinical Laboratory Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.
| | - Beili Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Corresponding authors. Clinical Laboratory Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Corresponding author. Clinical Laboratory Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.
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12
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Dahmer M, Jennings A, Parker M, Sanchez-Pinto LN, Thompson A, Traube C, Zimmerman JJ. Pediatric Critical Care in the Twenty-first Century and Beyond. Crit Care Clin 2023; 39:407-425. [PMID: 36898782 DOI: 10.1016/j.ccc.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pediatric critical care addresses prevention, diagnosis, and treatment of organ dysfunction in the setting of increasingly complex patients, therapies, and environments. Soon burgeoning data science will enable all aspects of intensive care: driving facilitated diagnostics, empowering a learning health-care environment, promoting continuous advancement of care, and informing the continuum of critical care outside the intensive care unit preceding and following critical illness/injury. Although novel technology will progressively objectify personalized critical care, humanism, practiced at the bedside, defines the essence of pediatric critical care now and in the future.
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Affiliation(s)
- Mary Dahmer
- Division of Critical Care, Department of Pediatrics, University of Michigan, 1500 East Medical Center Drive, F6790/5243, Ann Arbor, MI, USA
| | - Aimee Jennings
- Division of Critical Care Medicine, Advanced Practice, FA.2.112, Seattle Children's Hospital, 4800 Sandpoint Way Northeast, Seattle, WA 98105, USA
| | - Margaret Parker
- Department of Pediatrics, Stony Brook University, 7762 Bloomfield Road, Easton, MD 21601, USA
| | - Lazaro N Sanchez-Pinto
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 73, Chicago, IL 60611-2605, USA
| | - Ann Thompson
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medicine, 525 East 68th Street, Box 225, New York, NY 10065, USA
| | - Jerry J Zimmerman
- Department of Pediatrics, FA.2.300B Seattle Children's Hospital, 4800 Sandpoint Way Northeast, Seattle, WA 98105, USA; Pediatric Critical Care Medicine, Seattle Children's Hospital, Harborview Medical Center, University of Washington, School of Medicine, FA.2.300B, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA.
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13
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Lee RY, Kross EK, Torrence J, Li KS, Sibley J, Cohen T, Lober WB, Engelberg RA, Curtis JR. Assessment of Natural Language Processing of Electronic Health Records to Measure Goals-of-Care Discussions as a Clinical Trial Outcome. JAMA Netw Open 2023; 6:e231204. [PMID: 36862411 PMCID: PMC9982698 DOI: 10.1001/jamanetworkopen.2023.1204] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
IMPORTANCE Many clinical trial outcomes are documented in free-text electronic health records (EHRs), making manual data collection costly and infeasible at scale. Natural language processing (NLP) is a promising approach for measuring such outcomes efficiently, but ignoring NLP-related misclassification may lead to underpowered studies. OBJECTIVE To evaluate the performance, feasibility, and power implications of using NLP to measure the primary outcome of EHR-documented goals-of-care discussions in a pragmatic randomized clinical trial of a communication intervention. DESIGN, SETTING, AND PARTICIPANTS This diagnostic study compared the performance, feasibility, and power implications of measuring EHR-documented goals-of-care discussions using 3 approaches: (1) deep-learning NLP, (2) NLP-screened human abstraction (manual verification of NLP-positive records), and (3) conventional manual abstraction. The study included hospitalized patients aged 55 years or older with serious illness enrolled between April 23, 2020, and March 26, 2021, in a pragmatic randomized clinical trial of a communication intervention in a multihospital US academic health system. MAIN OUTCOMES AND MEASURES Main outcomes were natural language processing performance characteristics, human abstractor-hours, and misclassification-adjusted statistical power of methods of measuring clinician-documented goals-of-care discussions. Performance of NLP was evaluated with receiver operating characteristic (ROC) curves and precision-recall (PR) analyses and examined the effects of misclassification on power using mathematical substitution and Monte Carlo simulation. RESULTS A total of 2512 trial participants (mean [SD] age, 71.7 [10.8] years; 1456 [58%] female) amassed 44 324 clinical notes during 30-day follow-up. In a validation sample of 159 participants, deep-learning NLP trained on a separate training data set from identified patients with documented goals-of-care discussions with moderate accuracy (maximal F1 score, 0.82; area under the ROC curve, 0.924; area under the PR curve, 0.879). Manual abstraction of the outcome from the trial data set would require an estimated 2000 abstractor-hours and would power the trial to detect a risk difference of 5.4% (assuming 33.5% control-arm prevalence, 80% power, and 2-sided α = .05). Measuring the outcome by NLP alone would power the trial to detect a risk difference of 7.6%. Measuring the outcome by NLP-screened human abstraction would require 34.3 abstractor-hours to achieve estimated sensitivity of 92.6% and would power the trial to detect a risk difference of 5.7%. Monte Carlo simulations corroborated misclassification-adjusted power calculations. CONCLUSIONS AND RELEVANCE In this diagnostic study, deep-learning NLP and NLP-screened human abstraction had favorable characteristics for measuring an EHR outcome at scale. Adjusted power calculations accurately quantified power loss from NLP-related misclassification, suggesting that incorporation of this approach into the design of studies using NLP would be beneficial.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kevin S. Li
- Division of Biomedical and Health Informatics, Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
| | - James Sibley
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
| | - Trevor Cohen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Biomedical and Health Informatics, Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
| | - William B. Lober
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Biomedical and Health Informatics, Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Health Systems and Population Health, University of Washington, Seattle
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14
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When More Could Mean Less Intervention: The Tale Of Tracheostomy Timing in Critical Illness. Crit Care Med 2023; 51:333-335. [PMID: 36661461 DOI: 10.1097/ccm.0000000000005753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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15
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Radhakrishnan NS, Lukose K, Cartwright R, Sleiman A, Matey N, Lim D, LeGault T, Pollard S, Gravina N, Southwick FS. Prospective application of the interdisciplinary bedside rounding checklist 'TEMP' is associated with reduced infections and length of hospital stay. BMJ Open Qual 2022; 11:bmjoq-2022-002045. [PMID: 36588303 PMCID: PMC9723909 DOI: 10.1136/bmjoq-2022-002045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/05/2022] [Indexed: 12/09/2022] Open
Abstract
Protocols that enhance communication between nurses, physicians and patients have had a variable impact on the quality and safety of patient care. We combined standardised nursing and physician interdisciplinary bedside rounds with a mnemonic checklist to assure all key nursing care components were modified daily. The mnemonic TEMP allowed the rapid review of 11 elements. T stands for tubes assuring proper management of intravenous lines and foleys; E stands for eating, exercise, excretion and sleep encouraging a review of orders for diet, exercise, laxatives to assure regular bowel movements, and inquiry about sleep; M stands for monitoring reminding the team to review the need for telemetry and the frequency of vital sign monitoring as well as the need for daily blood tests; and P stands for pain and plans reminding the team to discuss pain medications and to review the management plan for the day with the patient and family. Faithful implementation eliminated central line-associated bloodstream infections and catheter-associated urinary tract infections and resulted in a statistically significant reduction in average hospital length of stay of 13.3 hours, one unit achieving a 23-hour reduction. Trends towards reduced 30-day readmissions (20% down to 10%-11%) were observed. One unit improved the percentage of patients who reported nurses and doctors always worked together as a team from a 56% baseline to 75%. However, the combining of both units failed to demonstrate statistically significant improvement. Psychologists well versed in implementing behavioural change were recruiting to improve adherence to our protocols. Following training physicians and nurses achieved adherence levels of over 70%. A high correlation (r2=0.69) between adherence and reductions in length of stay was observed emphasising the importance of rigorous training and monitoring of performance to bring about meaningful and reliable improvements in the efficiency and quality of patient care.
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Affiliation(s)
- Nila S Radhakrishnan
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kiran Lukose
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Richard Cartwright
- Office of Clinical Quality and Patient Safety, University of Florida Health, Gainesville, Florida, USA
| | - Andressa Sleiman
- Department of Psychology, University of Florida, Gainesville, Florida, USA
| | - Nicholas Matey
- Department of Psychology, University of Florida, Gainesville, Florida, USA
| | - Duke Lim
- Department of Nursing, University of Florida Health, Gainesville, Florida, USA
| | - Tiffany LeGault
- Department of Nursing, University of Florida Health, Gainesville, Florida, USA
| | - Sapheria Pollard
- Department of Nursing, University of Florida Health, Gainesville, Florida, USA
| | - Nicole Gravina
- Department of Psychology, University of Florida, Gainesville, Florida, USA
| | - Frederick S Southwick
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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16
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Hollenberg SM, Janz DR, Hua M, Malesker M, Qadir N, Rochwerg B, Sessler CN, Tatem G, Rice TW. COVID-19: Lessons Learned, Lessons Unlearned, Lessons for the Future. Chest 2022; 162:1297-1305. [PMID: 35952767 PMCID: PMC9512535 DOI: 10.1016/j.chest.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 07/10/2022] [Accepted: 08/02/2022] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 pandemic has affected clinicians in many different ways. Clinicians have their own experiences and lessons that they have learned from their work in the pandemic. This article outlines a few lessons learned from the eyes of CHEST Critical Care Editorial Board members, namely practices which will be abandoned, novel practices to be adopted moving forward, and proposed changes to the health care system in general. In an attempt to start the discussion of how health care can grow from the pandemic, the editorial board members outline their thoughts on these lessons learned.
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Affiliation(s)
- Steven M Hollenberg
- Emory Heart & Vascular Institute, Emory University School of Medicine, Atlanta, GA
| | - David R Janz
- Medical Critical Care Services, University Medical Center New Orleans, Louisiana State University School of Medicine New Orleans, New Orleans, LA
| | - May Hua
- Mailman School of Public Health, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Mark Malesker
- Department of Pharmacy Practice, School of Pharmacy and Health Professions, Creighton University, Omaha, NE
| | - Nida Qadir
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | | | - Curtis N Sessler
- Center for Adult Critical Care, Virginia Commonwealth University Health System, Richmond, VA
| | - Geneva Tatem
- Pulmonary and Critical Care Medicine Fellowship Program, Henry Ford Health, Detroit, MI
| | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN.
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17
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Toy D, Siegel MD, Rubinowitz AN. Imaging in the Intensive Care Unit. Semin Respir Crit Care Med 2022; 43:899-923. [PMID: 36442475 DOI: 10.1055/s-0042-1750041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.
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Affiliation(s)
- Dennis Toy
- Department of Medical Imaging, Colorado Permanente Medical Group, Lafayette, Colorado
| | - Mark D Siegel
- Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ami N Rubinowitz
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
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18
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Affiliation(s)
- William K Silverstein
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Choosing Wisely Canada, Toronto, ON, Canada
| | - Adina S Weinerman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
| | - Karen Born
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University Toronto, Toronto, ON, Canada
| | | | - Christopher P Moriates
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
- Costs of Care, Boston, MA, USA
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19
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Ito K, George N, Wilson J, Bowman J, Aaronson E, Ouchi K. Primary palliative care recommendations for critical care clinicians. J Intensive Care 2022; 10:20. [PMID: 35428371 PMCID: PMC9013119 DOI: 10.1186/s40560-022-00612-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 04/06/2022] [Indexed: 11/19/2022] Open
Abstract
Palliative care is an interdisciplinary care to optimize physical, psychosocial, and spiritual symptoms of patients and their families whose quality of life is impaired by serious, life-limiting illness. In 2021, the importance of providing palliative care in the intensive care unit (ICU) is well recognized by various studies to alleviate physical symptoms due to invasive treatments, to set patient-centered goals of care, and to provide end-of-life care. This paper summarizes the evidence known to date on primary palliative care delivered in the ICU settings. We will then discuss the potential benefits and harms of primary palliative care so that critical care clinicians are better equipped to decide what services might best improve the palliative care needs in their ICUs.
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20
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Cox C, Patel K, Cantu R, Akmyradov C, Irby K. Hypokalemia Measurement and Management in Patients With Status Asthmaticus on Continuous Albuterol. Hosp Pediatr 2022; 12:198-204. [PMID: 35018439 DOI: 10.1542/hpeds.2021-006265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Status asthmaticus is commonly treated in pediatric patients by using continuous albuterol, which can cause hypokalemia. The primary aim of this study was to determine if serial potassium monitoring is necessary by examining treatment frequency of hypokalemia. METHODS This retrospective analysis was performed in 185 pediatric patients admitted with status asthmaticus requiring continuous albuterol between 2017 and 2019. All patients were placed on intravenous fluids containing potassium. The primary outcome measure was the treatment of hypokalemia in relation to the number of laboratory draws for potassium levels. The secondary outcome measure was hypokalemia frequency and relation to the duration and initial dose of continuous albuterol. RESULTS Included were 156 patients with 420 laboratory draws (average, 2.7 per patient) for potassium levels. The median lowest potassium level was 3.40 mmol/L (interquartile range, 3.2-3.7). No correlation was found between initial albuterol dose and lowest potassium level (P = .52). Patients with hypokalemia had a mean albuterol time of 12.32 (SD, 15.76) hours, whereas patients without hypokalemia had a mean albuterol time of 11.50 (SD, 12.53) hours (P = .29). Potassium levels were treated 13 separate times. CONCLUSIONS The number of laboratory draws for potassium levels was high in our cohort, with few patients receiving treatment for hypokalemia beyond the potassium routinely added to maintenance fluids. Length of time on albuterol and dose of albuterol were not shown to increase the risk of hypokalemia. Serial laboratory measurements may be decreased to potentially reduce health care costs, pain, and anxiety surrounding needlesticks.
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Affiliation(s)
- Courtney Cox
- Divisions of Critical Care Medicine and.,Arkansas Children's Hospital, Little Rock, Arkansas
| | | | - Rebecca Cantu
- Hospital Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and University of Arkansas for Medical Sciences, Little Rock, Arkansas; and.,Arkansas Children's Hospital, Little Rock, Arkansas
| | | | - Katherine Irby
- Divisions of Critical Care Medicine and.,Arkansas Children's Hospital, Little Rock, Arkansas
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21
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Quintana Grijalba C, Rhee E, Zimmerman JJ. The ICU Liberation ABCDEF Bundle: Utilization Among Critically Ill Little Adults. Crit Care Med 2022; 50:163-165. [PMID: 34914649 DOI: 10.1097/ccm.0000000000005214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
| | - Eileen Rhee
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Seattle, WA.,Division of Bioethics and Palliative Care, University of Washington School of Medicine, Seattle, WA
| | - Jerry J Zimmerman
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Seattle, WA
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22
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McGain F, Corke M, Dade F, Hazard R, Grant D, French C. How often do routine ICU coagulation tests become abnormal? CRIT CARE RESUSC 2021; 23:423-426. [PMID: 38046688 PMCID: PMC10692608 DOI: 10.51893/2021.4.br2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Forbes McGain
- Western Health, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | | | | | | | | | - Craig French
- Western Health, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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23
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Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol. Ann Am Thorac Soc 2021; 18:336-346. [PMID: 32936675 DOI: 10.1513/annalsats.202002-088sd] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).
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Abstract
OBJECTIVES To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care. DATA SOURCES Semistructured narrative literature review and quantitative survey assessments. STUDY SELECTION English language publications that examined critical care practices in relation to reducing cost or waste. DATA EXTRACTION Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking. DATA SYNTHESIS Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices. CONCLUSIONS Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.
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Tang ST, Huang CC, Hu TH, Chou WC, Chuang LP, Chiang MC. Course and predictors of posttraumatic stress-related symptoms among family members of deceased ICU patients during the first year of bereavement. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:282. [PMID: 34353352 PMCID: PMC8340476 DOI: 10.1186/s13054-021-03719-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/01/2021] [Indexed: 11/10/2022]
Abstract
Background/Objective Death in intensive care units (ICUs) may increase bereaved family members’ risk for posttraumatic stress disorder (PTSD). However, posttraumatic stress-related symptoms (hereafter as PTSD symptoms) and their precipitating factors were seldom examined among bereaved family members and primarily focused on associations between PTSD symptoms and patient/family characteristics. We aimed to investigate the course and predictors of clinically significant PTSD symptoms among family members of deceased ICU patients by focusing on modifiable quality indicators for end-of-life ICU care. Method In this longitudinal observational study, 319 family members of deceased ICU patients were consecutively recruited from medical ICUs from two Taiwanese medical centers. PTSD symptoms were assessed at 1, 3, 6, and 13 months post-loss using the Impact of Event Scale-Revised (IES-R). Family satisfaction with end-of-life care in ICUs was assessed at 1 month post-loss. End-of-life care received in ICUs was documented over the patient’s ICU stay. Predictors for developing clinically significant PTSD symptoms (IES-R score ≥ 33) were identified by multivariate logistic regression with generalized estimating equation modeling. Results The prevalence of clinically significant PTSD symptoms decreased significantly over time (from 11.0% at 1 month to 1.6% at 13 months post-loss). Longer ICU stays (adjusted odds ratio [95% confidence interval] = 1.036 [1.006, 1.066]), financial insufficiency (3.166 [1.159, 8.647]), and reported use of pain medications (3.408 [1.230, 9.441]) by family members were associated with a higher likelihood of clinically significant PTSD symptoms among family members during bereavement. Stronger perceived social support (0.937 [0.911, 0.965]) and having a Do-Not-Resuscitate (DNR) order issued before the patient’s death (0.073 [0.011, 0.490]) were associated with a lower likelihood of clinically significant PTSD symptoms. No significant association was observed for family members’ satisfaction with end-of-life care (0.988 [0.944, 1.034]) or decision-making in ICUs (0.980 [0.944, 1.018]). Conclusions The likelihood of clinically significant PTSD symptoms among family members decreased significantly over the first bereavement year and was lower when a DNR order was issued before death. Enhancing social support and facilitating a DNR order may reduce the trauma of ICU death of a beloved for family members at risk for developing clinically significant PTSD symptoms. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03719-x.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Medical College, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, 333, Taiwan, R.O.C.. .,Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C.. .,Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, R.O.C..
| | - Chung-Chi Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C.,Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Tsung-Hui Hu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C.,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Li-Pang Chuang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, R.O.C
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Gupta R, Nallasamy K, Williams V, Saxena AK, Jayashree M. Prescription practice and clinical utility of chest radiographs in a pediatric intensive care unit: a prospective observational study. BMC Med Imaging 2021; 21:44. [PMID: 33750327 PMCID: PMC7941116 DOI: 10.1186/s12880-021-00576-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background Chest radiograph (CXR) prescribing pattern and practice vary widely among pediatric intensive care units (PICU). ‘On demand’ approach is increasingly recommended as against daily ‘routine’ CXRs; however, the real-world practice is largely unknown.
Methods This was a prospective observational study performed in children younger than 12 years admitted to PICU of a tertiary care teaching hospital in India. Data were collected on all consecutive CXRs performed between December 2016 and April 2017. The primary outcome was to assess the factors that were associated with higher chest radiograph prescriptions in PICU. Secondary outcomes were to study the indications, association with mechanical ventilation, image quality and avoidable radiation exposure. Results Of 303 children admitted during the study period, 159 underwent a total of 524 CXRs in PICU. Median (IQR) age of the study cohort was 2 (0.6–5) years. More than two thirds [n = 115, 72.3%] were mechanically ventilated. Most CXRs (n = 449, 85.7%) were performed on mechanically ventilated patients, amounting to a median (IQR) of 3 (2–5) radiographs per ventilated patient. With increasing duration of ventilation, the number of CXRs proportionately increased in the first two weeks of mechanical ventilation. In non-ventilated children, about two thirds (68%) underwent only one CXR. Majority of the prescriptions were on demand (n = 461, 88%). Most common indications were peri-procedure prescriptions (37%) followed by evaluation for respiratory disease status (24%). About 40% CXRs resulted in interventions; adjustment in ventilator settings (13.5%) was the most frequent intervention. In 26% (n = 138) of radiographs, image quality required improvement. One or more additional body part exposure other than chest and upper abdomen were noted 336 (64%) images. Children with > 3 CXR had higher PRISM III score, more often mechanically ventilated, had higher number of indwelling devices [mean (SD) 2.6 (1.2) vs. 1.7 (1.0)] and stayed longer in PICU [median (IQR) 11(7.5–18.5) vs. 6 (3–9)]. Conclusion On demand prescription was the prevalent practice in our PICU. Most non-ventilated children underwent only one CXR while duration of PICU stay and the number of devices determined the number of CXRs in mechanically ventilated children. Quality improvement strategies should concentrate on the process of acquisition of images and limiting the radiation exposure to unwanted body parts.
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Affiliation(s)
- Rajeev Gupta
- Pediatric Emergency and Intensive Care Units, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Karthi Nallasamy
- Pediatric Emergency and Intensive Care Units, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India.
| | - Vijai Williams
- Pediatric Emergency and Intensive Care Units, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Akshay Kumar Saxena
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Muralidharan Jayashree
- Pediatric Emergency and Intensive Care Units, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
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Beverina I, Borotto E, Novelli C, Radrizzani D, Brando B. Iatrogenic anaemia and transfusion thresholds in ICU patients with COVID-19 disease at a tertiary care hospital. Transfus Apher Sci 2021; 60:103068. [PMID: 33612448 PMCID: PMC7825903 DOI: 10.1016/j.transci.2021.103068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients with severe COVID-19 disease frequently develop anaemia as the result of multiple mechanisms and often receive transfusions. The aims of this study were to assess the impact of repeated blood samplings on patients' anaemic state using standard-volume tubes, in comparison with the hypothetical use of low-volume tubes and to evaluate the transfusion policy adopted. STUDY DESIGN AND METHODS Transfusion data of mechanically ventilated non-bleeding patients with COVID-19 disease hospitalized in ICU for a minimum of 20 days were recorded. The total volume of blood drawn for samplings with standard-volume tubes and the corresponding red blood cell mass (RBCM) removed during hospitalization for each patient were calculated and compared with the hypothetical use of low-volume tubes. RESULTS Twenty-four patients fulfilled the inclusion criteria. Ten patients were anaemic at ICU admission (41.7 %). Overall, 6658 sampling tubes were employed, for a total of 16,786 mL of blood. The median RBCM subtracted by blood samplings per patient accounted for about one third of the total patients' RBCM decrease until discharge. The use of low-volume tubes would have led to a median saving of about one third of the drawn RBCM. Eleven patients were transfused (45.8 %) at a mean Hb value of 7.7 (± 0.5) g/dL. CONCLUSION The amount of blood drawn for sampling has a significant role in the development of anaemia and the use of low-volume tubes could minimize the problem. Large high-powered studies are warranted to assess the more appropriate transfusion thresholds in non-bleeding critically ill patients with COVID-19 disease.
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Affiliation(s)
- Ivo Beverina
- Blood Transfusion Centre, ASST Ovest Milanese, Legnano General Hospital, Legnano, Italy.
| | - Erika Borotto
- Intensive Care Unit, ASST Ovest Milanese, Legnano General Hospital, Legnano, Italy
| | - Chiara Novelli
- Blood Transfusion Centre, ASST Ovest Milanese, Legnano General Hospital, Legnano, Italy
| | - Danilo Radrizzani
- Intensive Care Unit, ASST Ovest Milanese, Legnano General Hospital, Legnano, Italy
| | - Bruno Brando
- Blood Transfusion Centre, ASST Ovest Milanese, Legnano General Hospital, Legnano, Italy
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Abstract
BACKGROUND AND PURPOSE Daily chest radiographs (CXRs) have long been a routine part of care. However, evidence as well as changing technology has promoted on-demand CXRs as beneficial to patient care. We found that a substantial number of routine daily CXRs were being ordered, with some of the orders staying active even after extubation. METHODS Within a 19-bed adult medical ICU, we prospectively utilized 3 intervention phases from October 1, 2014, to February 28, 2018, to reduce routine CXRs. Nurse Practitioners (NP) initiated this quality improvement (QI) project, aiming to reduce the number of unnecessary of CXRs. Interventions included staff survey, routine CXR order removal, duplicate alerts, visual reminders, and an electronic clinical decision support tool. Monthly education of appropriate CXRs and bedside ultrasound were facilitated by NPs. The outcome measures of interest include: the number of CXRs per patient-day, the number of routine and on-demand CXRs, mortality rate, ICU length of stay, and ventilator days, radiation and cost. CONCLUSIONS Total number of CXRs per patient-day decreased by 36.1%. The proportion of routine CXRs decreased from 55.37% to 13.18%; on-demand orders increased, from 44.63% to 86.82%; and calculated radiation-exposure per census decreased, from 0.011 to 0.008 mSv. In addition, charges to patients for CXRs decreased by $7,750/month. ICU mortality and ventilator days per census remained stable. IMPLICATIONS FOR PRACTICE By an orchestrated process that included creating awareness and desire to change CXR ordering practices, we were able to decrease routine CXRs and increase on-demand utilization while maintaining counterbalance measures.
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Hooper KP, Anstey MH, Litton E. Safety and efficacy of routine diagnostic test reduction interventions in patients admitted to the intensive care unit: A systematic review and meta-analysis. Anaesth Intensive Care 2021; 49:23-34. [PMID: 33554634 DOI: 10.1177/0310057x20962113] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Reducing unnecessary routine diagnostic testing has been identified as a strategy to curb wasteful healthcare. However, the safety and efficacy of targeted diagnostic testing strategies are uncertain. The aim of this study was to systematically review interventions designed to reduce pathology and chest radiograph testing in patients admitted to the intensive care unit (ICU). A predetermined protocol and search strategy included OVID MEDLINE, OVID EMBASE and the Cochrane Central Register of Controlled Trials from inception until 20 November 2019. Eligible publications included interventional studies of patients admitted to an ICU. There were no language restrictions. The primary outcomes were in-hospital mortality and test reduction. Key secondary outcomes included ICU mortality, length of stay, costs and adverse events. This systematic review analysed 26 studies (with more than 44,00 patients) reporting an intervention to reduce one or more diagnostic tests. No studies were at low risk of bias. In-hospital mortality, reported in seven studies, was not significantly different in the post-implementation group (829 of 9815 patients, 8.4%) compared with the pre-intervention group (1007 of 9848 patients, 10.2%), (relative risk 0.89, 95% confidence intervals 0.79 to 1.01, P = 0.06, I2 39%). Of the 18 studies reporting a difference in testing rates, all reported a decrease associated with targeted testing (range 6%-72%), with 14 (82%) studies reporting >20% reduction in one or more tests. Studies of ICU targeted test interventions are generally of low quality. The majority report substantial decreases in testing without evidence of a significant difference in hospital mortality.
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Affiliation(s)
- Katherine P Hooper
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Matthew H Anstey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia.,Intensive Care Unit, St John of God Subiaco Hospital, Perth, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia.,Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia.,Intensive Care Unit, St John of God Subiaco Hospital, Perth, Australia
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Litton E, Atkinson H, Anstey J, Anstey M, Campbell LT, Forbes A, Hahn R, Hooper K, Kasza J, Knapp S, McGain F, Ngyuen N, Pilcher D, Reddi B, Reid C, Robinson S, Thompson K, Webb S, Young P. Optimising a targeted test reduction intervention for patients admitted to the intensive care unit: The Targeted Intensive Care Test Ordering Cluster Trial intervention. Aust Crit Care 2021; 34:419-426. [PMID: 33526330 DOI: 10.1016/j.aucc.2020.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/03/2020] [Accepted: 11/15/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Approaches to routine diagnostic testing in the intensive care unit include time-scheduled testing and targeted testing. Blood tests and chest radiographs requested on a routine, time-scheduled basis may reduce the risk of missing important findings. Targeted testing, considering individual patient needs, may reduce unnecessary testing, wasted clinician time, and costs. However, existing evidence of targeted testing interventions is generally of low quality, and the optimal testing approach is uncertain. OBJECTIVES The aim of the study was to describe the development of an intervention to reduce unnecessary diagnostic test ordering by clinicians working in intensive care, with the aim of informing the design of a pivotal clinical trial. METHODS The Capability, Opportunity, Motivation-Behaviour model was used as a theoretical framework for change. The intervention components were informed by systematically identifying, assessing, and classifying targeted testing interventions in behavioural terms. Feedback from intensive care clinicians and patients was sought using surveys and a consumer reference group. RESULTS The mean percentage of routine tests considered unnecessary by 201 intensive care clinicians was 33 (standard deviation = 16). When presented with a statement of the pros and cons for targeted versus liberal testing (n = 154), 93 (60%) consumer survey respondents preferred a more liberal approach, 33 (21%) preferred a more restrictive approach, and 28 (18%) were unsure. There were 24 behavioural interventions identified and incorporated into the final intervention. This had five major components: (i) a management committee to acquire, disseminate, and coordinate intervention-related information, (ii) a targeted testing guideline for sites, (iii) educational material for sites, (iv) site medical and nursing champions, and (v) site audit and feedback. CONCLUSIONS Although surveyed intensive care clinicians report substantial unnecessary routine diagnostic testing, on the basis of currently available evidence, consumers prefer a more liberal approach. This feedback, and a framework to identify behavioural interventions, has been used to inform the design of a proposed targeted testing clinical trial.
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Affiliation(s)
- Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia.
| | - Helen Atkinson
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - James Anstey
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Matthew Anstey
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Lewis T Campbell
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Andrew Forbes
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Rebecca Hahn
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Katherine Hooper
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Jessica Kasza
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Sharon Knapp
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Forbes McGain
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Nhi Ngyuen
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - David Pilcher
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Benjamin Reddi
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Chris Reid
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Suzanne Robinson
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Kelly Thompson
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Steve Webb
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Paul Young
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
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Lo ML, Huang CC, Hu TH, Chou WC, Chuang LP, Chiang MC, Wen FH, Tang ST. Quality Assessments of End-of-Life Care by Medical Record Review for Patients Dying in Intensive Care Units in Taiwan. J Pain Symptom Manage 2020; 60:1092-1099.e1. [PMID: 32650138 DOI: 10.1016/j.jpainsymman.2020.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT/OBJECTIVE Essential indicators of high-quality end-of-life care in intensive care units (ICUs) have been established but examined inconsistently and predominantly with small samples, mostly from Western countries. Our study goal was to comprehensively measure end-of-life-care quality delivered in ICUs using chart-derived process-based quality measures for a large cohort of critically ill Taiwanese patients. METHODS For this observational study, patients with APACHE II score ≥20 or goal of palliative care and with ICU stay exceeding three days (N = 326) were consecutively recruited and followed until death. RESULTS Documentation of process-based indicators for Taiwanese patients dying in ICUs was variable (8.9%-96.3%), but high for physician communication of the patient's poor prognosis to his/her family members (93.0%), providing specialty palliative-care consultations (73.3%), a do-not-resuscitate order in place at death (96.3%), death without cardiopulmonary resuscitation (93.5%), and family presence at patient death (76.1%). Documentation was infrequent for social-worker involvement (8.9%) and interdisciplinary family meetings to discuss goals of care (22.4%). Patients predominantly (79.8%) continued life-sustaining treatments (LSTs) until death and died with full life support, with 88.3% and 58.9% of patients dying with mechanical ventilation support and vasopressors, respectively. CONCLUSIONS Taiwanese patients dying in ICUs heavily used LSTs until death despite high prevalences of documented prognostic communication, providing specialty palliative-care consultations, having a do-not-resuscitate order in place, and death without cardiopulmonary resuscitation. Family meetings should be actively promoted to facilitate appropriate end-of-life-care decisions to avoid unnecessary suffering from potentially inappropriate LSTs during the last days of life.
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Affiliation(s)
- Mei-Ling Lo
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Chung-Chi Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Tsung-Hui Hu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Li-Pang Chuang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, R.O.C
| | - Siew Tzuh Tang
- School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C.
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Hill-Strathy M, Pinkerton PH, Thompson TA, Wendt A, Collins A, Cohen R, BComm WO, Cameron T, Lin Y, Lau W, Lieberman L, Callum J. Evaluating the appropriateness of platelet transfusions compared with evidence-based platelet guidelines: An audit of platelet transfusions at 57 hospitals. Transfusion 2020; 61:57-71. [PMID: 33078852 DOI: 10.1111/trf.16134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/27/2020] [Accepted: 08/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Platelet transfusions are used to prevent or control bleeding in patients with thrombocytopenia or platelet dysfunction. The pretransfusion platelet count threshold has been studied extensively in multiple patient settings yielding high-quality evidence that has been summarized in several comprehensive evidence-based platelet guidelines. STUDY DESIGN AND METHODS A prospective 12-week audit of consecutive platelet transfusions using validated and evidence-based adjudication criteria was conducted. Patient demographic, laboratory, and transfusion details were collected with an electronic audit tool. Each order was adjudicated either electronically or independently by two transfusion medicine physicians. The aim was to determine platelet transfusion appropriateness and common scenarios with deviations from guidelines. RESULTS Fifty-seven (38%) of 150 hospitals provided data on 1903 platelet orders, representing 90% of platelet usage in the region during the time period. Overall, 702 of 1693 adult (41.5%) and 133 of 210 pediatric orders (63.3%) were deemed inappropriate. The most common inappropriate platelet order was for prophylaxis in the absence of bleeding or planned procedure in patients with hypoproliferative thrombocytopenia and a platelet count over 10 x 109 /L (53% of inappropriate orders in adults and 45% in pediatrics). Platelet transfusions ordered with either a preprinted transfusion order set (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.44-2.73) or technologist prospective screening (OR, 1.40; 95% CI, 1.10-1.78) were more likely to be appropriate. CONCLUSION There is a discrepancy between clinical practice and evidence-based platelet guidelines. Broad educational and system changes will be needed to align platelet transfusion practice with guideline recommendations.
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Affiliation(s)
- MaryJane Hill-Strathy
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of St Andrews, Fife, UK
| | - Peter H Pinkerton
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Troy A Thompson
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Alison Wendt
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Allison Collins
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Robert Cohen
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Wendy Owens BComm
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Tracy Cameron
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
| | - Wendy Lau
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
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Maley JH, Stevens JP. Low-Value Diagnostic Imaging in the Intensive Care Unit: A Teachable Moment. JAMA Intern Med 2020; 180:1368-1369. [PMID: 32730564 DOI: 10.1001/jamainternmed.2020.2681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Jason H Maley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston.,Beth Israel Deaconess Center for Healthcare Delivery Science, Boston, Massachusetts
| | - Jennifer P Stevens
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Beth Israel Deaconess Center for Healthcare Delivery Science, Boston, Massachusetts
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The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives. Nurs Outlook 2020; 68:626-636. [PMID: 32739096 DOI: 10.1016/j.outlook.2020.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. PURPOSE This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. METHOD An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. FINDINGS A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. DISCUSSION A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.
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Implementation of an Academic-to-Community Hospital Intensive Care Unit Quality Improvement Program. Qualitative Analysis of Multilevel Facilitators and Barriers. Ann Am Thorac Soc 2020; 16:877-885. [PMID: 30822096 DOI: 10.1513/annalsats.201810-735oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Implementation of evidence-based best practices is influenced by a variety of contextual factors. It is vital to characterize such factors to maintain high-quality care. Patients in the intensive care unit (ICU) are critically ill and require complex, interdisciplinary, evidence-based care to enable high-quality outcomes. Objectives: To identify facilitators and barriers to implementation of an academic-to-community hospital ICU interprofessional quality improvement program, "ICU Innovations." Methods: ICU Innovations is a multimodal quality improvement program implemented between 2014 and 2017 in six community ICUs in rural settings serving underserved patients in South Carolina. ICU Innovations includes quarterly on-site seminars and extensive behind the scenes facilitation to catalyze the implementation of evidence-based best practices. We use qualitative analysis to identify contextual factors related to program implementation processes. Guided by an implementation science framework, the Exploration, Adoption/Preparation, Implementation, Sustainment framework, we conducted semistructured key informant interviews with clinician champions at six community ICUs and six parallel interviews with ICU Innovations' leadership. We developed a qualitative coding template based on the framework and identified contextual factors associated with implementation. Standard data on hospital and ICU structure and processes of care were also collected. Results: Outer and inner factors interconnected dynamically to influence implementation of ICU Innovations. Collaborative engagement between the program developers and partner sites (outer context factor) and site program champion leadership and staff readiness for change (inner context factors) were key influences of implementation. Conclusions: This research focused on rural hospital ICUs with limited or nonexistent intensivist leadership. Although enthusiasm for the ICU Innovations program was initially high, implementation was challenging because of multiple contextual factors. Critical steps for implementation of evidence-based practice in rural hospitals include optimizing engagement with external collaborators, maximizing the role of a committed site champion, and conducting thorough site assessments to ensure staff and organizational readiness for change. Identifying barriers and facilitators to program implementation is an on-going process to tailor and improve program initiatives.
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Vermylen JH, Wayne DB, Cohen ER, McGaghie WC, Wood GJ. Promoting Readiness for Residency: Embedding Simulation-Based Mastery Learning for Breaking Bad News Into the Medicine Subinternship. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1050-1056. [PMID: 32576763 DOI: 10.1097/acm.0000000000003210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE It is challenging to add rigorous, competency-based communication skills training to existing clerkship structures. The authors embedded a simulation-based mastery learning (SBML) curriculum into a medicine subinternship to demonstrate feasibility and determine the impact on the foundational skill of breaking bad news (BBN). METHOD All fourth-year students enrolled in a medicine subinternship at Northwestern University Feinberg School of Medicine from September 2017 through August 2018 were expected to complete a BBN SBML curriculum. First, students completed a pretest with a standardized patient using a previously developed BBN assessment tool. Learners then participated in a 4-hour BBN skills workshop with didactic instruction, focused feedback, and deliberate practice with simulated patients. Students were required to meet or exceed a predetermined minimum passing standard (MPS) at posttest. The authors compared pretest and posttest scores to evaluate the effect of the intervention. Participant demographic characteristics and course evaluations were also collected. RESULTS Eighty-five students were eligible for the study, and 79 (93%) completed all components. Although 55/79 (70%) reported having personally delivered serious news to actual patients, baseline performance was poor. Students' overall checklist performance significantly improved from a mean of 65.0% (SD = 16.2%) items correct to 94.2% (SD = 5.9%; P < .001) correct. There was also statistically significant improvement in scaled items assessing quality of communication, and all students achieved the MPS at mastery posttest. All students stated they would recommend the workshop to colleagues. CONCLUSIONS It is feasible to embed SBML into a required clerkship. In the context of this study, rigorous SBML resulted in uniformly high levels of skill acquisition, documented competency, and was positively received by learners.
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Affiliation(s)
- Julia H Vermylen
- J.H. Vermylen is assistant professor, Department of Medicine and Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois. D.B. Wayne is professor, Department of Medicine and Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois. E.R. Cohen is research associate, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. W.C. McGaghie is professor, Department of Medical Education and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. G.J. Wood is associate professor, Department of Medicine and Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Vasher ST, Oppenheim IM, Sharma Basyal P, Lee EM, Hayes MM, Turnbull AE. Physician Self-assessment of Shared Decision-making in Simulated Intensive Care Unit Family Meetings. JAMA Netw Open 2020; 3:e205188. [PMID: 32427323 PMCID: PMC7237960 DOI: 10.1001/jamanetworkopen.2020.5188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Professional guidelines have identified key communication skills for shared decision-making for critically ill patients, but it is unclear how intensivists interpret and implement them. OBJECTIVE To compare the self-evaluations of intensivists reviewing transcripts of their own simulated intensive care unit family meetings with the evaluations of trained expert colleagues. DESIGN, SETTING, AND PARTICIPANTS A posttrial web-based survey of intensivists was conducted between January and March 2019. Intensivists reviewed transcripts of simulated intensive care unit family meetings in which they participated in a previous trial from October 2016 to November 2017. In the follow-up survey, participants identified if and how they performed key elements of shared decision-making for an intensive care unit patient at high risk of death. Transcript texts that intensivists self-identified as examples of key communication skills recommended by their professional society's policy on shared decision-making were categorized. MAIN OUTCOMES AND MEASURES Comparison of the evaluations of 2 blinded nonparticipant intensivist colleagues with the self-reported responses of the intensivists. RESULTS Of 116 eligible intensivists, 76 (66%) completed the follow-up survey (mean [SD] respondent age was 43.1 [8.1] years; 72% were male). Sixty-one of 76 intensivists reported conveying prognosis; however, blinded colleagues who reviewed the deidentified transcripts were less likely to report that prognosis had been conveyed than intensivists reviewing their own transcripts (42 of 61; odds ratio, 0.10; 95% CI, 0.01-0.44; P < .001). When reviewing their own transcript, intensivists reported presenting many choices, with the most common choice being code status. They also provided a variety of recommendations, with the most common being to continue the current treatment plan. Thirty-three participants (43%) reported that they offered care focused on comfort, but blinded colleagues rated only 1 (4%) as explaining this option in a clear manner. CONCLUSIONS AND RELEVANCE In this study, guidelines for shared decision-making and end of life care were interpreted by intensivists in disparate ways. In the absence of training or personalized feedback, self-assessment of communication skills may not be interpreted consistently.
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Affiliation(s)
- Scott T. Vasher
- Department of Internal Medicine, Division of Hospital Medicine at Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian M. Oppenheim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pragyashree Sharma Basyal
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emma M. Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Shapiro Institute for Education and Research at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alison E. Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Seidlein AH, Hannich A, Nowak A, Gründling M, Salloch S. Ethical aspects of time in intensive care decision making. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2019-105752. [PMID: 32332151 DOI: 10.1136/medethics-2019-105752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 03/06/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting.
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Affiliation(s)
- Anna-Henrikje Seidlein
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Arne Hannich
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Andre Nowak
- Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle(Saale), Germany
| | - Matthias Gründling
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - Sabine Salloch
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
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Abstract
PURPOSE OF REVIEW To provide an update on implementation efforts in the care of critically ill patients, with a focus on work published in the last 2 years. RECENT FINDINGS Only half of surveyed members of the multidisciplinary care team in the ICU were aware of the Choosing Wisely campaign, and of those that were, approximately one-third reported no implementation of the recommendations. Barriers to implementation of the ABCDE bundle extend to beyond patient-level domains, and include clinician-related, protocol-related, and other domains. Prospective audit and feedback approaches have demonstrated moderate success for improving the quality of antibiotic prescription practices in the ICU. SUMMARY Clinical research in intensive care has moved beyond simple discovery and dissemination. Best practices must be applied to effect change in ICU care, requiring the application of principles from implementation science. Future work should move beyond simple before-after evaluations to provide a stronger case for causal inference following implementation efforts.
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Oppenheim IM, Lee EM, Vasher ST, Zaeh SE, Hart JL, Turnbull AE. Effect of Intensivist Communication in a Simulated Setting on Interpretation of Prognosis Among Family Members of Patients at High Risk of Intensive Care Unit Admission: A Randomized Trial. JAMA Netw Open 2020; 3:e201945. [PMID: 32236533 PMCID: PMC7113731 DOI: 10.1001/jamanetworkopen.2020.1945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Importance Discordance about prognosis between a patient's health care decision-making surrogate and the treating intensivist is common in the intensive care unit (ICU). Empowering families, friends, and caregivers of patients who are critically ill to make informed decisions about care is important, but it is unclear how best to communicate prognostic information to surrogates when a patient is expected to die. Objective To determine whether family members, who are often health care decision-making surrogates, interpret intensivists as being more optimistic when questions about prognosis in the ICU are answered indirectly. Design, Setting, and Participants This web-based randomized trial was conducted between September 27, 2019, and October 17, 2019, among a national sample of adult children, spouses, partners, or siblings of people with chronic obstructive pulmonary disease who were receiving long-term oxygen therapy. Participants were shown video vignettes depicting an intensivist answering a standardized question about the prognosis of a patient at high risk of death on day 3 of ICU admission. Participants were excluded if they had worked as a physician, nurse, or advanced health care practitioner. Data were analyzed from October 18, 2019, to November 12, 2019. Interventions Participants were randomized to view 1 of 4 intensivist communication styles in response to the question "What do you think is most likely to happen?": (1) a direct response (control), (2) an indirect response comparing the patient's condition with that of other patients, (3) an indirect response describing the patient's deteriorating physiological condition, or (4) redirection to a discussion of the patient's values and goals. Main Outcomes and Measures Participant responses to 2 questions: (1) "If you had to guess, what do you think the doctor thinks is the chance that your loved one will survive this hospitalization?" and (2) "What do you think are the chances that your loved one will survive this hospitalization?" answered using a 0% to 100% probability scale. Results Among 302 participants (median [interquartile range] age, 49 [38-59] years; 204 [68%] women) included in the trial, 165 (55%) were adult children of the individual with chronic obstructive pulmonary disease; 77 participants were randomized to view a direct response, 77 participants were randomized to view an indirect response referencing other patients, 68 participants were randomized to view an indirect response referencing physiological condition, and 80 participants were randomized to view a redirection response. Compared with participants who viewed a direct response, participants who viewed an indirect response referencing other patients (β = 10 [95% CI, 1-19]; P = .03), physiological condition (β = 10 [95% CI, 0-19]; P = .04), or redirection to a discussion of the patient's values and goals (β = 19 [95% CI, 10-28]; P < .001) perceived the intensivist to have a significantly more optimistic prognostic estimate. Conclusions and Relevance These findings suggest that family members interpret indirect or redirection responses to questions about prognosis in the ICU setting as more optimistic than direct responses. Trial Registration ClinicalTrials.gov Identifier: NCT04239209.
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Affiliation(s)
- Ian M Oppenheim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emma M Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott T Vasher
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sandra E Zaeh
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joanna L Hart
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Shander A, Corwin HL. A Narrative Review on Hospital-Acquired Anemia: Keeping Blood where It Belongs. Transfus Med Rev 2020; 34:195-199. [PMID: 32507403 DOI: 10.1016/j.tmrv.2020.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 12/13/2022]
Abstract
Hospital-acquired anemia (HAA) is a prevalent condition that is independently associated with worse clinical outcomes including prolongation of hospital stay and increased morbidity and mortality. While multifactorial in general, iatrogenic blood loss has been long recognized as one of the key contributing factors to development and worsening of HAA during hospital stay. Patients can be losing over 50 mL of blood per day to diagnostic blood draws. Strategies such as elimination of unnecessary laboratory tests that are not likely to alter the course of management, use of pediatric-size or small-volume tubes for blood collection to reduce phlebotomy volumes and avoid blood wastage, use of closed blood sampling devices, and substituting invasive tests with point-of-care testing alone or bundled together have generally been shown to be effective in reducing the volume of iatrogenic blood loss, hemoglobin decline, and blood transfusions, with no negative impact on the availability of test results for the clinical team. These strategies are important components of Patient Blood Management programs and their adoption can lead to improved clinical outcomes for patients.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, TeamHealth Research Institute, Englewood Hospital and Medical Center, Englewood, NJ, USA.
| | - Howard L Corwin
- Department of Critical Care Medicine, Geisinger Health System, Danville, PA, USA
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Abstract
Objectives: The Critical Care Choosing Wisely Task Force recommends that intensivists offer patients at high risk for death or severe functional impairment the option of pursuing care focused on comfort. We tested the a priori hypothesis that intensivists who are prompted to document patient prognosis are more likely to disclose prognosis and offer comfort-focused care. Design: Randomized controlled trial (clinicaltrials.gov:). Setting: High-fidelity Simulation Center in Baltimore, MD. Participants: One hundred sixteen intensivists from 17 states. Intervention: All intensivists reviewed a paper-based medical record for a hypothetical patient on ICU day 3 and answered four survey questions about the patient’s medical management. Intensivists randomized to the intervention group answered three additional questions about patient prognosis. Thereafter, each intensivist participated in a standardized, video-recorded, simulated family meeting with an actor performing a standardized portrayal of the patient’s daughter. Measurements and Main Results: Two blinded intensivists reviewed deidentified written transcripts of all simulated family meetings. The primary outcome was the blinded reviewers’ assessment that the intensivist had presented the option of care focused entirely on comfort. Secondary outcomes included disclosing risk of death. All outcomes were planned prior to data collection. Among the 63 intensivists randomized to the intervention, 50 (79%) expected the patient to die during the hospitalization and 58 (92%) expected the patient to have new functional impairments preventing independent living. Intensivists in the intervention versus control group were no more likely to offer the option of care focused on comfort (13% vs 13%; 95% CI, −13% to 12%; p = 1.0) but were more likely to inform the daughter that her father was sick enough to die (68% vs 43%; 95% CI, 5–44%; p = 0.01). Conclusions: Documenting prognosis may help intensivists disclose prognosis to ICU proxies, but in isolation, it is unlikely to change the treatment options offered during initial family meetings.
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Adams JY, Rogers AJ, Schuler A, Marelich GP, Fresco JM, Taylor SL, Riedl AW, Baker JM, Escobar GJ, Liu VX. Association Between Peripheral Blood Oxygen Saturation (SpO 2)/Fraction of Inspired Oxygen (FiO 2) Ratio Time at Risk and Hospital Mortality in Mechanically Ventilated Patients. Perm J 2020; 24:19.113. [PMID: 32069205 DOI: 10.7812/tpp/19.113] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Acute respiratory failure requiring mechanical ventilation is a leading cause of mortality in the intensive care unit. Although single peripheral blood oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) ratios of hypoxemia have been evaluated to risk-stratify patients with acute respiratory distress syndrome, the utility of longitudinal SpO2/FiO2 ratios is unknown. OBJECTIVE To assess time-based SpO2/FiO2 ratios ≤ 150-SpO2/FiO2 time at risk (SF-TAR)-for predicting mortality in mechanically ventilated patients. METHODS Retrospective, observational cohort study of mechanically ventilated patients at 21 community and 2 academic hospitals. Association between the SF-TAR in the first 24 hours of ventilation and mortality was examined using multivariable logistic regression and compared with the worst recorded isolated partial pressure of arterial oxygen/fraction of inspired oxygen (P/F) ratio. RESULTS In 28,758 derivation cohort admissions, every 10% increase in SF-TAR was associated with a 24% increase in adjusted odds of hospital mortality (adjusted odds ratio = 1.24; 95% confidence interval [CI] = 1.23-1.26); a similar association was observed in validation cohorts. Discrimination for mortality modestly improved with SF-TAR (area under the receiver operating characteristic curve [AUROC] = 0.81; 95% CI = 0.81-0.82) vs the worst P/F ratio (AUROC = 0.78; 95% CI = 0.78-0.79) and worst SpO2/FiO2 ratio (AUROC = 0.79; 95% CI = 0.79-0.80). The SF-TAR in the first 6 hours offered comparable discrimination for hospital mortality (AUROC = 0.80; 95% CI = 0.79-0.80) to the 24-hour SF-TAR. CONCLUSION The SF-TAR can identify ventilated patients at increased risk of death, offering modest improvements compared with single SpO2/FiO2 and P/F ratios. This longitudinal, noninvasive, and broadly generalizable tool may have particular utility for early phenotyping and risk stratification using electronic health record data in ventilated patients.
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Affiliation(s)
- Jason Y Adams
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis, Sacramento
| | - Angela J Rogers
- Division of Pulmonary and Critical Care Medicine, Stanford University, CA
| | | | | | | | - Sandra L Taylor
- Department of Public Health Sciences, University of California, Davis, Sacramento
| | - Albert W Riedl
- Department of Public Health Sciences, University of California, Davis, Sacramento
| | | | | | - Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, CA
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Abstract
OBJECTIVES Incomplete patient data, either due to difficulty gathering and synthesizing or inappropriate data filtering, can lead clinicians to misdiagnosis and medical error. How completely ICU interprofessional rounding teams appraise the patient data set that informs clinical decision-making is unknown. This study measures how frequently physician trainees omit data from prerounding notes ("artifacts") and verbal presentations during daily rounds. DESIGN Observational study. SETTING Tertiary academic medical ICU with an established electronic health record and where physician trainees are the primary presenters during daily rounds. SUBJECTS Presenters (medical student or resident physician), interprofessional rounding team. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We quantified the amount and types of patient data omitted from photocopies of physician trainees' artifacts and audio recordings of oral ICU rounds presentations when compared with source electronic health record data. An audit of 157 patient presentations including 6,055 data elements across nine domains revealed 100% of presentations contained omissions. Overall, 22.9% of data were missing from artifacts and 42.4% from presentations. The interprofessional team supplemented only 4.1% of additional available data. Frequency of trainee data omission varied by data type and sociotechnical factors. The strongest predictor of trainee verbal omissions was a preceding failure to include the data on the artifact. Passive data gathering via electronic health record macros resulted in extremely complete artifacts but paradoxically predicted greater likelihood of verbal omission when compared with manual notation. Interns verbally omitted the most data, whereas medical students omitted the least. CONCLUSIONS In an academic rounding model reliant on trainees to preview and select data for presentation during ICU rounds, verbal appraisal of patient data was highly incomplete. Additional trainee oversight and education, improved electronic health record tools, and novel academic rounding paradigms are needed to address this potential source of medical error.
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Choosing Wisely in Critical Care: Results of a National Survey From the Critical Care Societies Collaborative. Crit Care Med 2020; 47:331-336. [PMID: 30768500 DOI: 10.1097/ccm.0000000000003496] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Over-utilization of tests, treatments, and procedures is common for hospitalized patients in ICU settings. American Board of Internal Medicine Foundation's Choosing Wisely campaign tasked professional societies to identify sources of overuse in specialty care practice. The purpose of this study was to assess how critical care clinicians were implementing the Critical Care Societies Collaborative Choosing Wisely recommendations in clinical practice. DESIGN Descriptive survey methodology with use of Research Electronic Data Capture (https://projectredcap.org/) sent via email newsletter blast or to individual emails of the 150,000 total members of the organizations. SETTING National survey. SUBJECTS ICU physicians, nurses, advanced practice providers including nurse practitioners and physician assistants, and pharmacist members of four national critical care societies in the United States. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A six-question survey assessed what Choosing Wisely recommendations had been implemented in ICU settings and if the impact was assessed. A total of 2,520 responses were received from clinicians: nurses (61%; n = 1538), physicians (25.9%; n = 647), advanced practice providers (10.5%; n = 263), and pharmacists (2.1%; n = 52), reflecting a 1.6% response rate of the total membership of 150,000 clinicians. Overall, 1,273 respondents (50.6%) reported they were familiar with the Choosing Wisely campaign. Respondents reported that Choosing Wisely recommendations had been integrated in a number of ways including being implemented in clinical care (n = 817; 72.9%), through development of a specific clinical protocol or institutional guideline (n = 736; 65.7%), through development of electronic medical record orders (n = 626; 55.8%), or with integration of longitudinal tracking using an electronic dashboard (n = 213; 19.0%). Some respondents identified that a specific quality improvement initiative was developed related to the Choosing Wisely recommendations (n = 468; 41.7%), or that a research initiative had been conducted (n = 156; 13.9%). CONCLUSIONS The results provide information on the application of the Choosing Wisely recommendations to clinical practice from a small sample of critical care clinicians. However, as only half of the respondents report implementation, additional strategies are needed to promote the Choosing Wisely recommendations to make impactful change to improve care in ICU settings.
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Jackson Chornenki NL, James TE, Barty R, Liu Y, Rochwerg B, Heddle NM, Siegal DM. Blood loss from laboratory testing, anemia, and red blood cell transfusion in the intensive care unit: a retrospective study. Transfusion 2019; 60:256-261. [DOI: 10.1111/trf.15649] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/08/2019] [Accepted: 11/22/2019] [Indexed: 02/04/2023]
Affiliation(s)
| | - Tyler E. James
- Department of Medicine McMaster University Hamilton Ontario Canada
| | - Rebecca Barty
- Department of Medicine McMaster University Hamilton Ontario Canada
- McMaster Centre for Transfusion Research McMaster University Hamilton Ontario Canada
| | - Yang Liu
- Department of Medicine McMaster University Hamilton Ontario Canada
- McMaster Centre for Transfusion Research McMaster University Hamilton Ontario Canada
| | - Bram Rochwerg
- Department of Medicine McMaster University Hamilton Ontario Canada
- Department of Health Research Methods Evidence and Impact at McMaster Hamilton Ontario Canada
| | - Nancy M. Heddle
- Department of Medicine McMaster University Hamilton Ontario Canada
- McMaster Centre for Transfusion Research McMaster University Hamilton Ontario Canada
| | - Deborah M. Siegal
- Department of Medicine McMaster University Hamilton Ontario Canada
- Population Health Research Institute McMaster University Hamilton Ontario Canada
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'Less is more' in modern ICU: blessings and traps of treatment limitation. Intensive Care Med 2019; 46:110-112. [PMID: 31605150 DOI: 10.1007/s00134-019-05807-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022]
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To transfuse or not transfuse: an intensive appraisal of red blood cell transfusions in the ICU. Curr Opin Hematol 2019; 25:468-472. [PMID: 30281035 DOI: 10.1097/moh.0000000000000460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW This review is a critical appraisal of the current data comparing restrictive vs. liberal transfusion strategies for patients who are critically ill in ICUs. We focus on four subsets of critically ill patients: pediatric patients, patients with gastrointestinal bleeds, septic patients and patients undergoing cardiac surgery. RECENT FINDINGS Almost a decade after the TRICC trial, a randomized trial showing the safety of a restrictive transfusion threshold in critically ill patients, four large randomized controlled trials have shown that a restrictive transfusion strategy is safe in pediatric critically ill patients, patients with acute upper gastrointestinal bleeds, patients with septic shock and patients undergoing cardiac surgery. A large multicenter randomized trial is underway to determine the safety of a restrictive strategy in myocardial infarction. SUMMARY A restrictive transfusion threshold is recommended in nearly all critically ill patients. This is at least noninferior to more liberal transfusion practice; in addition, a restrictive threshold has shown improved outcomes in some patients and decreased chances of adverse events in patients. Judicious use of red cells improves patient outcome and protects the blood supply, a limited resource. More data are needed to determine appropriate transfusion threshold recommendations for patients with traumatic brain injury and acute coronary syndrome.
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Highlighting a Common Quality of Care Delivery Problem: Overuse of Low-value Healthcare Services. J Healthc Qual 2019; 40:201-208. [PMID: 28846551 DOI: 10.1097/jhq.0000000000000095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low-value healthcare services (LVHS) are defined as procedures delivered that provide little or no clinical benefit. Overuse of LVHS, or delivery when the risks exceed the benefits, contributes to excessive spending without improved outcomes. Furthermore, overuse contributes to healthcare waste. PURPOSE The primary purpose of this commentary is to (1) examine the problem of LVHS overuse and its impacts on quality care delivery and (2) propose factors to consider in developing quality measures to help reduce overuse and waste and thus improve patient outcomes. METHODS To inform and support this commentary, we conducted a limited review of the literature related to LVHS overuse, its consequences, and suggested solutions. Online search engines were used to identify research related to our primary areas of interest. RESULTS This commentary demonstrates that overuse and associated healthcare waste is growing among selected LVHS. The factors of overuse are multidimensional and poorly understood. Meanwhile, overuse of LVHS has financial consequences and impacts quality of care and outcomes. CONCLUSIONS Overuse of LVHS is common in the United States, leading to waste and suboptimal patient outcomes. Thus a need exists to address overuse and develop measures to capture a larger scope of services.
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