Care coordination in intensive care units: communicating across information spaces

Effectiveness of a self-assessment application in evaluating the care coordination competency of intensive care unit nurses in managing patients on life support: An intervention study

AIM

To examine the effectiveness of the feedback from the Nurses' Care Coordination Competency Scale (NCCCS) application (app) used for self-assessing the care coordination competency of intensive care unit (ICU) nurses in managing patients on life support.

METHODS

A non-randomized open-label study was conducted in Japan from November 2021 to March 2022. Participants were 318 ICU nurses from acute hospitals in Japan. They were divided manually into two groups based on their certification status. The intervention was immediate feedback on the results of the care coordination competency self-assessment through the NCCCS app; the control group performed the NCCCS survey with no feedback. The primary outcome was an increase in the NCCCS score 1 month after the intervention. Mann-Whitney U test was used to compare the scores of the intervention and control groups. Wilcoxon's signed rank sum test was used to compare the scores in the first and second NCCCS surveys.

RESULTS

Forty-one participants were lost to follow-up, leaving 277 participants (intervention = 141, control = 136) for analysis. One month later, NCCCS scores similarly increased in both groups. For nurses with at least 5 years of ICU experience (n = 152), the NCCCS score increased in the intervention group (n = 75) (rising point mean: 4.8, standard deviation [SD]: 9.8) compared with that in the control group (n = 77) (rising point mean: 1.3, SD: 8.3) (p = .048).

CONCLUSIONS

Feedback from the NCCCS app can improve care coordination behavior. However, a certain level of ICU experience may be required to translate feedback into improved behavior.

Ambulatory Care Coordination Data Gathering and Use

Care coordination is a crucial component of healthcare systems. However, little is known about data needs and uses in ambulatory care coordination practice. Therefore, the purpose of this study was to identify information gathered and used to support care coordination in ambulatory settings. Survey respondents (33) provided their demographics and practice patterns, including use of electronic health records, as well as data gathered and used. Most of the respondents were nurses, and they described varying practice settings and patterns. Although most described at least partial use of electronic health records, two respondents described paper documentation systems. More than 25% of respondents gathered and used most of the 72 data elements, with collection and use often occurring in multiple locations and contexts. This early study demonstrates significant heterogeneity in ambulatory care coordination data usage. Additional research is necessary to identify common data elements to support knowledge development in the context of a learning health system.

Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study

Few studies have investigated interruptions to the work of professionals practicing in inpatient hospitals, and even fewer take account of the functions that make up the system. Safety of care can be improved by considering avoidable interruptions during interactions between managerial and care delivery functions. The present study describes the characteristics of interruptions to the work of professionals working in the inpatient hospital sector, with respect to their typology, frequency, duration, and avoidability in the context of interactions between functions. This direct observational study of interruptions in hospital care was performed in the Pays de la Loire (west coast) area of France. A total of 23 teams (17 institutions) working in medical or surgical specialties (excluding intensive care) were included. Observations were performed between May and September 2019, and lasted seven consecutive hours per team. A pair of observers simultaneously observed the same professional for ∼30 min. Each occupational category was examined. Reported characteristics were: (i) the method and duration of the request, (ii) the location of interrupted and interrupting persons, (iii) the reaction of the interrupted person, (iv) the characteristics of the interrupting person, and (v) the classification of interrupted and interrupting tasks according to their function. An avoidable interruption was defined. Interruptions during interactions between professionals were categorised in terms of their function and avoidability. Descriptive statistical analyses (mean, standard deviation, and distribution) were run. In particular, cross-comparisons were run to highlight avoidability interruptions and interactions between managerial and care delivery functions during the working day, for different professional categories, and for the location of the request. Overall, 286 interrupted professionals were observed and 1929 interruptions were characterised. The majority of interruptions were due to a face-to-face request (58.7%), lasting ≤30 s (72.5%). Professionals engaged in the response in 49.3% of cases. A total of 57.4% of interruptions were avoidable. The average number of interruptions was 10.5 (SD = 3.2) per hour per professional. An analysis of avoidability and interactions between managerial and care delivery functions found that the period between 12:00 and 13:00 was the riskiest in terms of care safety. This study highlighted the characteristics of interruptions to the activity of professionals working in inpatient hospitals. Care teams could focus on making medical and nursing professionals much more aware of the importance of interruptions, and each team could decide how to best-manage interruptions, in the context of their specific working environment.

Task interruptions from the perspective of work functions: The development of an observational tool applied to inpatient hospital care in France The Team'IT tool

BACKGROUND

In France, hospital units responsible for providing inpatient care have few opportunities to address the issue of task interruptions. In Australia, the Dual Perspectives Method (DMP) has been developed to assess interruptions. The method makes it possible to link teamwork and interruptions, by considering the work functions that constitute the system.

OBJECTIVE

To develop a tool that can characterize interruptions from the point of view of work functions that is tailored to French hospital units providing inpatient care. The aim was to adapt the items recorded using the DPM and their response categories, and to study the acceptability of observing interruptions for participating teams.

METHOD

The items recorded in the DPM were translated and adapted taking into account the French definition of interruptions. This step identified 19 items that targeted the interrupted professional, and 16 that targeted the interrupting professional. The characteristics of interruptions were recorded in September 2019 among 23 volunteer teams in a region in western France. Two observers simultaneously observed the same professional. Observations lasted seven consecutive hours, and targeted all professional categories within the same team.

RESULTS

The characteristics of 1,929 interruptions were noted. The observation period was well-received by teams. The following terminology regarding the work functions of the interrupting professional was clarified: "coordination of institutional resources", in relation to "the establishment's support processes", "patient services", and "the patient's social life". We believe that our categorization of response modes is exhaustive.

CONCLUSIONS

We have developed an observational tool, Team'IT, which is tailored to inpatient hospital care in France. Its implementation is the first step in a system to support teams in managing interruptions, and will enable them to reflect on their working methods, and whether interruptions can be avoided. Our work is part of an approach that seeks to improve and enhance the safety of professional practices, by contributing to the longstanding, complex debate about the flow and effectiveness of patient care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03786874 (December 26, 2018).

A specialized multi-disciplinary care program for children with sepsis and multiple organ dysfunction-associated immune dysregulation

The complex physiology and medical requirements of children with sepsis and multiple organ dysfunction syndrome (MODS) challenge traditional care coordination models. While the involvement of multiple clinical subspecialty services is often necessary to support different care processes and individual organ system dysfunctions, it can also delay the diagnostic process, monitoring, and treatment. The logistics of coordinating with many specialty providers for critically ill patients are challenging and time consuming, and often can result in fragmented communication. To address these and other related issues, we developed a new multi-disciplinary consult service focused on streamlining diagnostics, management, and communication for patients with sepsis and MODS-associated immune dysregulation. The service, called the Program in Inflammation, Immunity, and the Microbiome (PrIIMe), is now a hospital-wide clinical consult service at our institution caring for a broad group of patients with immune dysregulation, particularly focusing on patients with sepsis and MODS. In this paper, we summarize the development, structure, and function of the program, as well as the initial impact. This information may be helpful to clinicians and healthcare leaders who are developing multi-disciplinary consult services for children with complex care needs, especially those with sepsis and MODS-associated immune dysregulation. IMPACT: The care of children with sepsis and multiple organ dysfunction-associated immune dysregulation requires rapid and flexible involvement of multiple clinical subspecialists that is difficult to achieve without fragmented care and delayed decision making. In this narrative review we describe the development, structure, and function of a multi-disciplinary consult service at a children's hospital dedicated to helping coordinate management and provide continuity of care for patients with sepsis and multiple organ dysfunction-associated immune dysregulation. This information may be helpful to clinicians and healthcare leaders who are developing multi-disciplinary consult services for children with complex care needs, especially those with sepsis and MODS-associated immune dysregulation.

Asymmetry of Authority or Information Underlying Insufficient Communication Associated with a Risk of Crashes or Incidents in Passenger Railway Transportation

Similar crashes or incidents may recur as a result of insufficient communication in uncertain and risky situations that potentially threaten safety. The common root causes of insufficient communication across a series of incidents and crashes must be explored in detail to prevent a vicious circle of similar incidents or crashes from occurring. This study summarizes a series of incidents and crashes (derailment due to excessive train speed) at JR West at the West Japan Railway Company (JR West) that are considered to have arisen from insufficient communication. The incidents included (i) resuming train service without confirming the number of passengers on board and leaving passengers behind the station at Higashi-Hiroshima station, (ii) continuing train service in spite of an apparent risk of a crash detected at Okayama station, and (iii) leaving the crack of the train hood as it was at Kokura station. We discuss the causes of insufficient communication (particularly in relation to the sharing of information) among the three branches of staff—the station staff, the conductor and train driver, and the train operation management center—that led to the incidents or crashes. Two factors contributed to the insufficient communication in the series of incidents and crashes: (a) Asymmetry of authority, which hinders the discussion of issues openly and equally among the branches concerned. (b) An unacceptable level of knowledge or information for all branches concerned.

Concerns About Verbal Communication in the Operating Room: A Field Study

OBJECTIVE

To assess verbal communication patterns which could contribute to poor performance among surgical team members in an operating room.

BACKGROUND

There exist certain challenges in communication in health care settings. Poor communication can have negative effects on the performance of a surgical team and patient safety. A communication pattern may be associated with poor performance when the process of sending and receiving information is interrupted or the content of conversation is not useful.

METHOD

This cross-sectional field study was conducted with 54 surgical teams working in two Iranian hospitals during 2015. Two observers recorded all verbal communications in an operating room. An in-depth assessment of various annotated transcripts by an expert panel was used to assess verbal communication patterns in the operating room.

RESULTS

Verbal communication patterns which could contribute to poor performance were observed in 63% of the surgeries, categorized as communication failures (17 events), protests (23 events), and irrelevant conversations (164 events). The anesthesiologists and the circulating nurses had the most concerning communication patterns. The failure of devices and poor planning were important factors that contributed to concerning patterns.

CONCLUSION

Concerning patterns of verbal communication are not rare in operating rooms. Analyzing the annotated transcripts of surgeries can conduce to identifying all these patterns, and their causes. Concerning communication patterns can be reduced in the operating room by providing interventions, properly planning for surgeries, and fixing defective devices.

APPLICATION

The method used in this study can be followed to assess communication problems in operating rooms and to find solutions.

Beyond ‘find and fix’: improving quality and safety through resilient healthcare systems

Objective

The aim was to develop a method based on resilient healthcare principles to proactively identify system vulnerabilities and quality improvement interventions.

Design

Ethnographic methods to understand work as it is done in practice using concepts from resilient healthcare, the Concepts for Applying Resilience Engineering model and the four key activities that are proposed to underpin resilient performance—anticipating, monitoring, responding and learning.

Setting

Accident and Emergency Department (ED) and the Older People’s Unit (OPU) of a large teaching hospital in central London.

Participants

ED—observations 104 h, and 14 staff interviews. OPU—observations 60 h, and 15 staff interviews.

Results

Data were analysed to identify targets for quality improvement. In the OPU, discharge was a complex and variable process that was difficult to monitor. A system to integrate information and clearly show progress towards discharge was needed. In the ED, patient flow was identified as a complex high-intensity activity that was not supported by the existing data systems. The need for a system to integrate and display information about both patient and organizational factors was identified. In both settings, adaptive capacity was limited by the absence of systems to monitor the work environment.

Conclusions

The study showed that using resilient healthcare principles to inform quality improvement was feasible and focused attention on challenges that had not been addressed by traditional quality improvement practices. Monitoring patient and workflow in both the ED and the OPU was identified as a priority for supporting staff to manage the complexity of the work.

Critical care nurses' perception of care coordination competency for management of mechanically ventilated patients

AIMS AND OBJECTIVES

To evaluate nurses' care coordination competency for mechanically ventilated patients in intensive care units (ICUs) of Saudi Arabia (SA).

BACKGROUND

ICUs are increasingly using multidisciplinary approach to provide critical care. Functionality gaps remain within these teams preventing optimum performance, including a lack of adequate care coordination in the management of mechanically ventilated (MV) patients.

DESIGN

A cross-sectional survey of ICU nurses working across 20 hospitals in SA.

METHODS

The Nurses' Care Coordination Competency Scale (NCCCS) survey for MV patients was administered to all the nurses to assess their care coordination competence. The data were analysed using Student's t test, ANOVA and linear regression. Reporting of this research follows STROBE guidelines.

RESULTS

A total of 254 nurses participated in the survey. The overall NCCCS mean score was 3.94 (±0.69) out of a 5-point scale. Also, the "promoting team cohesion factor (Factor 1)" had a mean score of 3.90 (±0.77), the "understanding care coordination needs factor (Factor II)" had a mean score of 4.00 (±0.77), the "aggregating and disseminating information factor (Factor III)" had a mean score of 4.05 (±0.76), and the "devising and clearly articulating the care vision factor (Factor IV)" had a mean score of 3.78 (±0.87). The mean overall NCCCS score was 4.10 among Indians, 3.98 among Filipinos and 3.81 among Saudi nationals.

CONCLUSION

There were a high overall score and subscale scores of nurses' care coordination competence for mechanically ventilated patients, but few gaps were identified in some of the items.

RELEVANCE TO CLINICAL PRACTICE

The results provide information on the status and gaps in ICU nurses' care coordination competencies to address the needs of mechanically ventilated critically ill patients. The NCCCS can be utilised as an educational tool for nurses who are new to the ICU work environment.

Development of the Nurses' Care Coordination Competency Scale for mechanically ventilated patients in critical care settings in Japan: Part 2 Validation of the scale

OBJECTIVES

To confirm the validity and reliability of the nurses' care coordination competency draft scale for mechanically ventilated patients in Japan.

DESIGN/METHOD

In this cross sectional observational study, a draft scale measuring care coordination was distributed to 2189 nurses from 73 intensive care units in Japan from February-March 2016. Based on the valid 887 responses, we examined construct validity including structural validity (exploratory and confirmatory factor analysis), convergent and discriminant validity and internal consistency reliability.

SETTINGS

73 Intensive care units.

RESULTS

Exploratory factor analyses yielded four factors with 22 items: 1) promoting team cohesion, 2) understanding care coordination needs, 3) aggregating and disseminating information, 4) devising and clearly articulating the care vision. The four-factor model was confirmed using a confirmatory factor analysis (confirmatory fit index=0.942, root mean square error of approximation=0.062). Scale scores positively correlated with team leadership and clearly identified and discriminated nurses' attributes. Cronbach's alpha coefficient for each subscale was between 0.812 and 0.890, and 0.947 for the total scale.

CONCLUSIONS

The Nurses' Care Coordination Competency Scale with four factors and 22 items had sufficient validity and reliability. The scale could make care coordination visible in nursing practice. Future research on the relationship between this scale and patient outcomes is needed.

Nonlinear dynamical systems for theory and research in ergonomics

Nonlinear dynamical systems (NDS) theory offers new constructs, methods and explanations for phenomena that have in turn produced new paradigms of thinking within several disciplines of the behavioural sciences. This article explores the recent developments of NDS as a paradigm in ergonomics. The exposition includes its basic axioms, the primary constructs from elementary dynamics and so-called complexity theory, an overview of its methods, and growing areas of application within ergonomics. The applications considered here include: psychophysics, iconic displays, control theory, cognitive workload and fatigue, occupational accidents, resilience of systems, team coordination and synchronisation in systems. Although these applications make use of different subsets of NDS constructs, several of them share the general principles of the complex adaptive system. Practitioner Summary: Nonlinear dynamical systems theory reframes problems in ergonomics that involve complex systems as they change over time. The leading applications to date include psychophysics, control theory, cognitive workload and fatigue, biomechanics, occupational accidents, resilience of systems, team coordination and synchronisation of system components.

Two sides to every story: The Dual Perspectives Method for examining interruptions in healthcare

Interruptions are widely considered a problem in healthcare. Results from observation and experimental studies have guided extensive mitigation efforts, but the effectiveness of interventions remains mixed. We have built on current theories and methods for studying interruptions to develop a novel observational approach - the Dual Perspectives Method - for examining interruptions from the perspectives of the different work functions in an Intensive Care Unit (ICU). We detail the method and provide representative examples of the insights it offers, such as why interruptions happen, the role they play, and the consequences of preserving them or eliminating them. We anticipate that the Dual Perspectives Method will help us to arrive at a better basis on which to draw conclusions about interruptions, and will lead to the development of appropriate and sustainable interventions to ensure the effective and safe functioning of the work system under examination.

An Integrative Literature Review of Organisational Factors Associated with Admission and Discharge Delays in Critical Care

The literature shows that delayed admission to the intensive care unit (ICU) and discharge delays from the ICU are associated with increased adverse events and higher costs. Identifying factors related to delays will provide information to practice improvements, which contribute to better patient outcomes. The aim of this integrative review was to explore the incidence of patients' admission and discharge delays in critical care and to identify organisational factors associated with these delays. Seven studies were included. The major findings are as follows: (1) explanatory research about discharge delays is scarce and one study on admission delays was found, (2) delays are a common problem mostly due to organisational factors, occurring in 38% of admissions and 22–67% of discharges, and (3) redesigning care processes by improving information management and coordination between units and interdisciplinary teams could reduce discharge delays. In conclusion, patient outcomes can be improved through efficient and safe care processes. More exploratory research is needed to identify factors that contribute to admission and discharge delays to provide evidence for clinical practice improvements. Shortening delays requires an interdisciplinary and multifaceted approach to the whole patient flow process. Conclusions should be made with caution due to the limited number of articles included in this review.

Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit

OBJECTIVE

To assess the impact of EHR technology on the work and workflow of ICU physicians and compare time spent by ICU resident and attending physicians on various tasks before and after EHR implementation.

DESIGN

EHR technology with electronic order management (CPOE, medication administration and pharmacy system) and physician documentation was implemented in October 2007.

MEASUREMENT

We collected a total of 289 h of observation pre- and post-EHR implementation. We directly observed the work of residents in three ICUs (adult medical/surgical ICU, pediatric ICU and neonatal ICU) and attending physicians in one ICU (adult medical/surgical ICU).

RESULTS

EHR implementation had an impact on the time distribution of tasks as well as the temporal patterns of tasks. After EHR implementation, both residents and attending physicians spent more of their time on clinical review and documentation (40% and 55% increases, respectively). EHR implementation also affected the frequency of switching between tasks, which increased for residents (from 117 to 154 tasks per hour) but decreased for attendings (from 138 to 106 tasks per hour), and the temporal flow of tasks, in particular around what tasks occurred before and after clinical review and documentation. No changes in the time spent in conversational tasks or the physical care of the patient were observed.

CONCLUSIONS

The use of EHR technology has a major impact on ICU physician work (e.g., increased time spent on clinical review and documentation) and workflow (e.g., clinical review and documentation becoming the focal point of many other tasks). Further studies should evaluate the impact of changes in physician work on the quality of care provided.

Human Factors in Critical Care Medical Environments

The purpose of this chapter on human factors in critical care medical environments is to provide a systematic review of the human factors and ergonomics contributions that led to significant improvements in patient safety over the last five decades. The review will focus on issues that contributed to patient injury and fatalities and how human factors and ergonomics can improve performance of providers in critical care. Given the complexity of critical care delivery, a review needs to cover a wide range of subjects. In this review, I take a sociotechnical systems perspective on critical care and discuss the people, their technical and nontechnical skills, the importance of teamwork, technology, and ergonomics in this complex environment. After a description of the importance of a safety climate, the chapter will conclude with a summary on how human factors and ergonomics can improve quality in critical care delivery.

Crucial information needs of ICU charge nurses in Finland and Greece

AIMS

To describe crucial information needs of ICU charge nurses, and to compare these needs in two countries in Europe.

BACKGROUND

ICU charge nurses are on the front line for ensuring that the activities of their units are running smoothly. They are accountable for making sure that the right tasks are performed under the right circumstances, with the right people, at the right time.

DESIGN AND PARTICIPANTS

An online survey based on a previous observation study regarding the ad hoc decision-making of ICU shift leaders. A total of 257 Finnish and 50 Greek ICU charge nurses participated in this study, from 17 Finnish and 16 Greece ICUs for adults.

METHODS

Our survey incorporated 122 statements divided into six dimensions (patient admission, organization and management of work, allocation of staff, allocation of material, special treatments and patient discharge) with a rating scale from 0 to 10. Analysis involved descriptive statistics. Mann-Whitney U and Kruskal-Wallis tests were used to compare the answers of the two countries. Validity was verified with confirmatory factor analysis and the reliability was tested with Cronbach's α values.

RESULTS

The most crucial information needs of ICU charge nurses concerned the overall organization and management of work. Both staff-related and individual patient-related information was needed. Information needs of Finnish and Greek charge nurses concerned similar kinds of situations in ICUs. However, there were some differences that might depend on the cultural differences between the countries.

CONCLUSIONS

Accurate and real-time information is a prerequisite for ICU charge nurses' ad hoc decision-making during daily care management. Identification of the most crucial information is needed when tools for information management are developed.

RELEVANCE TO CLINICAL PRACTICE

The results of this study indicated that a major portion of immediate information needs of ICU charge nurses are internationally common in similar settings.

National survey focusing on the crucial information needs of intensive care charge nurses and intensivists: same goal, different demands

Background

Although information technology adequately supports clinical care in many intensive care units (ICUs), it provides much poorer support for the managerial information needed to coordinate multi-professional care. To gain a general view of the most crucial multi-professional information needs of ICU shift leaders a national survey was conducted, focusing on the information needs of charge nurses and intensivists.

Methods

Based on our previous observation study an online survey was developed, containing 122 information need statements related to the decision-making of ICU shift leaders. Information need statements were divided into six dimensions: patient admission, organisation and management of work, allocation of staff and material resources, special treatments, and patient discharge. This survey involved all ICU shift leaders (n = 738) who worked in any of the 17 highest level ICUs for adults in university hospitals in Finland during the autumn of 2009. Both charge nurses’ and intensivists’ crucial information needs for care coordination were evaluated.

Results

Two hundred and fifty-seven (50%) charge nurses and 96 (43%) intensivists responded to the survey. The consistency of the survey was found to be good (Cronbach’s α scores between .87–.97, with a total explanatory power of 64.53%). Altogether, 57 crucial information needs for care coordination were found; 22 of which were shared between shift leaders. The most crucial of these information needs were related to organisation and management, patient admission, and allocation of staff resources. The associations between working experience, or shift leader acting frequencies, and crucial information needs were not statistically significant. However, a statistically significant difference was found between the number of ICU beds and the ICU experience of charge nurses with information needs, under the dimension of organisation and management of work. The information needs of charge nurses and intensivists differed. Charge nurses’ information needs related to care coordination, were more varied, and concerned issues at a unit level, whereas intensivists focused on direct patient care.

Conclusions

The reliability and validity of our survey was found to be good. Our study findings show that care coordination at an ICU is a collaborative process among ICU shift leaders with multiprofessional information needs related to organisation and management, patient admission, and allocation of staff resources. Study findings can be used to identify the most crucial information needs of ICU shift leaders when new information technology is developed to support managerial decision-making during care coordination.