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Krewulak KD, Knight G, Irwin A, Morrissey J, Stelfox HT, Bagshaw SM, Zuege D, Roze des Ordons A, Fiest K, Parhar KKS. Acceptability of the Venting Wisely pathway for use in critically ill adults with hypoxaemic respiratory failure and acute respiratory distress syndrome (ARDS): a qualitative study protocol. BMJ Open 2024; 14:e075086. [PMID: 38806421 PMCID: PMC11138268 DOI: 10.1136/bmjopen-2023-075086] [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] [Received: 04/26/2023] [Accepted: 05/03/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Hypoxaemic respiratory failure (HRF) affects nearly 15% of critically ill adults admitted to an intensive care unit (ICU). An evidence-based, stakeholder-informed multidisciplinary care pathway (Venting Wisely) was created to standardise the diagnosis and management of patients with HRF and acute respiratory distress syndrome. Successful adherence to the pathway requires a coordinated team-based approach by the clinician team. The overall aim of this study is to describe the acceptability of the Venting Wisely pathway among critical care clinicians. Specifically, this will allow us to (1) better understand the user's experience with the intervention and (2) determine if the intervention was delivered as intended. METHODS AND ANALYSIS This qualitative study will conduct focus groups with nurse practitioners, physicians, registered nurses and registered respiratory therapists from 17 Alberta ICUs. We will use template analysis to describe the acceptability of a multicomponent care pathway according to seven constructs of acceptability: (1) affective attitude;,(2) burden, (3) ethicality, (4) intervention coherence, (5) opportunity costs, (6) perceived effectiveness and (7) self-efficacy. This study will contribute to a better understanding of the acceptability of the Venting Wisely pathway. Identification of areas of poor acceptability will be used to refine the pathway and implementation strategies as ways to improve adherence to the pathway and promote its sustainability. ETHICS AND DISSEMINATION The study was approved by the University of Calgary Conjoint Health Research Ethics Board. The results will be submitted for publication in a peer-reviewed journal and presented at a scientific conference. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT04744298.
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Affiliation(s)
- Karla D Krewulak
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gwen Knight
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Andrea Irwin
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jeanna Morrissey
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Henry Thomas Stelfox
- University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Sean M Bagshaw
- University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Danny Zuege
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | | - Kirsten Fiest
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Ken Kuljit Singh Parhar
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Gruß I, Dawson T, Kaplan CD, Pihlstrom DJ, Fellows JL, Polk DE. Utilizing deliberative engagement for identifying implementation strategy priorities: lessons learned from an online deliberative forum with dental professionals. Implement Sci Commun 2023; 4:119. [PMID: 37735706 PMCID: PMC10512594 DOI: 10.1186/s43058-023-00496-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Selecting effective implementation strategies to support guideline-concordant dental care is a complex process. We are drawing on data collected during the DISGO study to reflect on barriers we encountered in implementing a deliberative engagement process for discussing implementation strategies relevant to the evidence-based guideline targeted in this intervention. The goal is to identify factors that may influence the success of deliberative engagement as a technique to involve healthcare staff in identifying priorities for implementation strategies. METHODS We drew on online chat transcripts from the deliberative engagement forums collected during the DISGO study. The chat transcripts were automatically generated for each discussion and captured the written exchanges between participants and moderators in all participating dental clinics. Chat transcripts were analyzed following a content analysis approach. RESULTS Our findings revealed barriers to the successful implementation of deliberative engagement in the context of the DISGO study. Participants were not familiar with the materials that had been prepared for the forum and lacked familiarity with the topic of deliberation. Participants also did not share divergent viewpoints and reinforced existing ideas rather than introducing new ideas. CONCLUSIONS In order to ensure that obstacles that were encountered in this study are not repeated, it is important to carefully consider how staff can effectively be prepared for the deliberations. Participants must be familiar with the content of the guideline, and most questions about the content and evidence should be answered before the deliberative engagement sessions. If perspectives among staff on a guideline are homogenous, briefing materials should introduce perspectives that complement existing views among staff. It is also necessary to create an environment in which staff are comfortable introducing opinions that may not be held by the majority of colleagues. TRIAL REGISTRATION This project is registered at ClinicalTrials.gov with ID NCT04682730. The trial was first registered on 12/18/2020. https://clinicaltrials.gov/ct2/show/NCT04682730 .
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Affiliation(s)
- Inga Gruß
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR, 97227, USA.
| | - Tim Dawson
- The Art of Democracy, LLC. 51 Roycroft Avenue, Pittsburgh, PA, 15228, USA
| | - Charles D Kaplan
- Sunrise Community Counseling Center, 537 S. Alvarado St, Los Angeles, CA, 90057, USA
| | - Daniel J Pihlstrom
- Permanente Dental Associates, 500 NE Multnomah St #100, Portland, OR, 97232, USA
| | - Jeffrey L Fellows
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR, 97227, USA
| | - Deborah E Polk
- School of Dental Medicine, University of Pittsburgh, 3501 Terrace Street, Pittsburgh, PA, 15260, USA
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McCarthy S, Laaksonen R, Silvari V. Transition of care from adult intensive care settings - implementing interventions to improve medication safety and patient outcomes. BMJ Qual Saf 2022; 31:565-568. [PMID: 35508374 DOI: 10.1136/bmjqs-2021-014443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/03/2022]
Affiliation(s)
| | - Raisa Laaksonen
- Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
| | - Virginia Silvari
- School of Pharmacy, University College Cork, Cork, Ireland.,Pharmacy Department, Cork University Hospital, Cork, Ireland
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Optimizing red blood cell transfusion practices in the intensive care unit: a multi-phased health technology reassessment. Int J Technol Assess Health Care 2021; 38:e10. [DOI: 10.1017/s0266462321001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Health technology reassessment (HTR) is a process to manage existing health technologies to ensure ongoing optimal use. A model to guide HTR was developed; however, there is limited practical experience. This paper addresses this knowledge gap through the completion of a multi-phase HTR of red blood cell (RBC) transfusion practices in the intensive care unit (ICU).
Objective
The HTR consisted of three phases and here we report on the final phase: the development, implementation, and evaluation of behavior change interventions aimed at addressing inappropriate RBC transfusions in an ICU.
Methods
The interventions, comprised of group education and audit and feedback, were co-designed and implemented with clinical leaders. The intervention was evaluated through a controlled before-and-after pilot feasibility study. The primary outcome was the proportion of potentially inappropriate RBC transfusions (i.e., with a pre-transfusion hemoglobin of 70 g/L or more).
Results
There was marked variability in the monthly proportion of potentially inappropriate RBC transfusions. Relative to the pre-intervention phase, there was no significant difference in the proportion of potentially inappropriate RBC transfusions post-intervention. Lessons from this work include the importance of early and meaningful engagement of clinical leaders; tailoring the intervention modalities; and, efficient access to data through an electronic clinical information system.
Conclusions
It was feasible to design, implement, and evaluate a tailored, multi-modal behavior change intervention in this small-scale pilot study. However, early evaluation of the intervention revealed no change in technology use leading to reflection on the important question of how the HTR model needs to be improved.
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Plotnikoff KM, Krewulak KD, Hernández L, Spence K, Foster N, Longmore S, Straus SE, Niven DJ, Parsons Leigh J, Stelfox HT, Fiest KM. Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care. Crit Care 2021; 25:438. [PMID: 34920729 PMCID: PMC8684123 DOI: 10.1186/s13054-021-03857-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/04/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Critically ill patients require complex care and experience unique needs during and after their stay in the intensive care unit (ICU). Discharging or transferring a patient from the ICU to a hospital ward or back to community care (under the care of a general practitioner) includes several elements that may shape patient outcomes and overall experiences. The aim of this study was to answer the question: what elements facilitate a successful, high-quality discharge from the ICU? METHODS This scoping review is an update to a review published in 2015. We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases from 2013-December 3, 2020 including adult, pediatric, and neonatal populations without language restrictions. Data were abstracted using different phases of care framework models, themes, facilitators, and barriers to the ICU discharge process. RESULTS We included 314 articles from 11,461 unique citations. Two-hundred and fifty-eight (82.2%) articles were primary research articles, mostly cohort (118/314, 37.6%) or qualitative (51/314, 16.2%) studies. Common discharge themes across all articles included adverse events, readmission, and mortality after discharge (116/314, 36.9%) and patient and family needs and experiences during discharge (112/314, 35.7%). Common discharge facilitators were discharge education for patients and families (82, 26.1%), successful provider-provider communication (77/314, 24.5%), and organizational tools to facilitate discharge (50/314, 15.9%). Barriers to a successful discharge included patient demographic and clinical characteristics (89/314, 22.3%), healthcare provider workload (21/314, 6.7%), and the impact of current discharge practices on flow and performance (49/314, 15.6%). We identified 47 discharge tools that could be used or adapted to facilitate an ICU discharge. CONCLUSIONS Several factors contribute to a successful ICU discharge, with facilitators and barriers present at the patient and family, health care provider, and organizational level. Successful provider-patient and provider-provider communication, and educating and engaging patients and families about the discharge process were important factors in a successful ICU discharge.
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Affiliation(s)
- Kara M Plotnikoff
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Laura Hernández
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Krista Spence
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Nadine Foster
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Shelly Longmore
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada
- Department of Geriatric Medicine, Faculty of Medicine, University of Toronto, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Faculty of Health, School of Health Administration, Dalhousie University, Sir Charles Tupper Medical Building, 2nd Floor, 5850 College Street, Halifax, NS, B3H 4R2, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Psychiatry, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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Qi M, Lopa S, Adambekov S, Harris JA, Mansuria S, Edwards RP, Linkov F. Same-day discharge after minimal invasive hysterectomy: Applications for improved value of care. Eur J Obstet Gynecol Reprod Biol 2021; 259:140-145. [PMID: 33667895 DOI: 10.1016/j.ejogrb.2021.02.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/16/2021] [Accepted: 02/20/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Hysterectomy is one of the most common surgical procedures. Same-day discharge (SDD) is increasingly utilized for minimally invasive hysterectomies, but its uptake varies across healthcare systems and surgical specialties. An evidence-based initiative was developed to aid in the incorporation of SDD into the practice of minimally invasive hysterectomy (MIH) in the UPMC Health System. The objective of this study was to identify trends of SDD utilization across various gynecologic specialties at UPMC, as well as evaluate the impact of SDD on length of stay (LOS) and complications after the implementation of SDD initiative. STUDY DESIGN We retrospectively identified 5554 patients who underwent MIH between 2014 and 2017 and were eligible for SDD, as determined by physicians and authorized by patients' insurance plans. Multivariable logistic regression models evaluated the trend of SDD utilization among four specialty types (general gynecologists, urogynecologists, specialized minimally invasive surgeons, and oncologists) and trends in complications. Multivariable logistic and linear regression models were applied to compare complications and LOS between patients with SDD vs. those with overnight admissions. RESULTS SDD utilization increased from 28.55% to 74.99% during the study period. SDD significantly increased over the study period for all specialty types, with urogynecologists having the highest uptake from 3.9% in 2014 to 95.8% in 2017 (p<.01). After adjusting for year, specialty types, MIH procedure type, and total case time, SDD utilization was associated with shorter mean LOS (p<.01); such that mean LOS was 764.43 min (95% CI: 735.46-793.40) for SDD patients and 2041.84 min (95% CI: 2015.99-2067.70) for patients with overnight admissions. SDD was also associated with 42% lower odds (95% CI: 0.37-0.93, p=.02) of complications compared with patients with overnight admissions. CONCLUSION Same-day discharge uptake increased over years and was associated with lower odds of complications and decreased length of stay. More studies are needed to explore same-day discharge process to improve patient outcomes, patient satisfaction, and value of care.
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Affiliation(s)
- Meiyuzhen Qi
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, United States.
| | - Samia Lopa
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women's Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States; Magee-Womens Research Institute, Pittsburgh, PA 15213, United States
| | - Shalkar Adambekov
- Al-Farabi Kazakh National University, Department of Epidemiology, Biostatistics, and Evidence Based Medicine, 71 al-Farabi Ave, Almaty, 050040, Kazakhstan; UNICEF Kazakhstan Country Office, Block 1, 10a Beibitshilik Street, Nur-Sultan, 010000, Kazakhstan
| | - John A Harris
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women's Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States; Magee-Womens Research Institute, Pittsburgh, PA 15213, United States
| | - Suketu Mansuria
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women's Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Robert P Edwards
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women's Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States; UPMC Hillman Cancer Center, Pittsburgh, PA 15232, United States
| | - Faina Linkov
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women's Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States; Magee-Womens Research Institute, Pittsburgh, PA 15213, United States; UPMC Hillman Cancer Center, Pittsburgh, PA 15232, United States; Department of Health Administration and Public Health, John G. Rangos Sr. School of Health Sciences, Duquesne University, Pittsburgh, PA 15219, United States
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Williams G, Fulbrook P, Kleinpell R, Alberto L. The Fifth International Survey of Critical Care Nursing Organizations: Implications for Policy. J Nurs Scholarsh 2020; 52:652-660. [PMID: 33089651 PMCID: PMC7756856 DOI: 10.1111/jnu.12599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 01/09/2023]
Abstract
Purpose To examine the activities, concerns, and expectations of critical care nurses and professional critical care nursing organizations worldwide. Design A descriptive survey methodology was used. This study is the fifth worldwide quadrennial review of its type to monitor variations in critical care nursing needs and provide robust evidence to inform policy related to critical care nursing practice. Methods The fifth World Federation of Critical Care Nurses international survey of critical care nursing organizations was emailed to potential participants from countries with critical care nursing organizations or known critical care nurse leaders. Data were collected online. Responses were entered into SPSS version 23 software (IBM Corp., Armonk, NY, USA) and analyzed by geographical region and national wealth group. Findings Eighty‐two national representative respondents participated in the survey, of whom two thirds (n = 56, 68%) had an established critical care nursing organization in their country. The five most important issues identified were working conditions, teamwork, staffing levels, the need for formal practice guidelines and competencies, and wages. The top five critical care nursing organization services that were considered to be of most importance were professional representation, as well as provision of workshops and education forums, national conferences, practice standards and guidelines, and local conferences. The most important contributions expected from the World Federation of Critical Care Nurses were standards for clinical practice and professional practice, international conferences, professional representation, and study and education grants. Conclusions The results highlight priority areas for critical care nursing and reinforce the need to address factors that can inform critical care nursing policy and practice. Results of this survey should be incorporated into strategic action plans at the national and international levels. Clinical Relevance Nursing leaders, policymakers, and other interested stakeholders should consider these findings when planning critical care workforce requirements. Interested parties should work collaboratively to inform recommendations for further policy and action.
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Affiliation(s)
- Ged Williams
- Chief Nursing Officer, Mafraq Hospital, United Arab Emirates and Adjunct Professor, School of Nursing & Midwifery, Griffith University, Queensland, Australia
| | - Paul Fulbrook
- Professor of Nursing, School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Nursing Director, Nursing Research & Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia and Honorary Professor, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruth Kleinpell
- Assistant Dean for Clinical Scholarship and Professor, Vanderbilt University School of Nursing, TN and Professor, Rush University College of Nursing, Chicago, USA
| | - Laura Alberto
- Professor, School of Nursing, Universidad del Salvador, Argentina
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Pastva AM, Coyle PC, Coleman SW, Radman MD, Taylor KM, Jones SB, Bushnell CD, Rosamond WD, Johnson AM, Duncan PW, Freburger JK. Movement Matters, and So Does Context: Lessons Learned From Multisite Implementation of the Movement Matters Activity Program for Stroke in the Comprehensive Postacute Stroke Services Study. Arch Phys Med Rehabil 2020; 102:532-542. [PMID: 33263286 DOI: 10.1016/j.apmr.2020.09.386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022]
Abstract
The purpose of this Special Communication is to discuss the rationale and design of the Movement Matters Activity Program for Stroke (MMAP) and explore implementation successes and challenges in home health and outpatient therapy practices across the stroke belt state of North Carolina. MMAP is an interventional component of the Comprehensive Postacute Stroke Services Study, a randomized multicenter pragmatic trial of stroke transitional care. MMAP was designed to maximize survivor health, recovery, and functional independence in the community and to promote evidence-based rehabilitative care. MMAP provided training, tools, and resources to enable rehabilitation providers to (1) prescribe physical activity and exercise according to evidence-based guidelines and programs, (2) match service setting and parameters with survivor function and benefit coverage, and (3) align treatment with quality metric reporting to demonstrate value-based care. MMAP implementation strategies were aligned with the Expert Recommendations for Implementing Change project, and MMAP site champion and facilitator survey feedback were thematically organized into the Consolidated Framework for Implementation Research domains. MMAP implementation was challenging, required modification and was affected by provider- and system-level factors. Program and study participation were limited and affected by practice priorities, productivity standards, and stroke patient volume. Sites with successful implementation appeared to have empowered MMAP champions in vertically integrated systems that embraced innovation. Findings from this broad evaluation can serve as a road map for the design and implementation of other comprehensive, complex interventions that aim to bridge the currently disconnected realms of acute care, postacute care, and community resources.
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Affiliation(s)
- Amy M Pastva
- Duke University School of Medicine, Durham, North Carolina.
| | - Peter C Coyle
- University of Pittsburgh School of Health and Rehabilitation Science, Pittsburgh, Pennsylvania
| | - Sylvia W Coleman
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Meghan D Radman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Karen M Taylor
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Sara B Jones
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Wayne D Rosamond
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anna M Johnson
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Pamela W Duncan
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Janet K Freburger
- University of Pittsburgh School of Health and Rehabilitation Science, Pittsburgh, Pennsylvania
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Salous AK, D'Adamo CR, Rubin J, Zweigle J, Cantos EA, Lopez-Perez M, Lannom M, Dodenhoff SM, Coleman J, Ahuja V. Stakeholder Engagement Significantly Decreased Colorectal Surgical Site Infections. Surg Infect (Larchmt) 2020; 22:305-309. [PMID: 32697676 DOI: 10.1089/sur.2019.134] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Patients and care providers raised concerns about the increased incidence of colorectal surgical site infection (SSI) at a community hospital in Baltimore compared with peer institutions. Patients and Methods: A preliminary analysis was performed that identified several modifiable targets for interventions to reduce SSIs in this patient population. The intervention focused on wide engagement of all stakeholder groups across the spectrum of care including physicians, pharmacists, nurses, administrators, and patients. The engagement process involved hospital-wide educational sessions, adoption and implementation of the best clinical guidelines, and utilization of the electronic medical record system to reinforce compliance and ensure quality control. Data for SSIs in colorectal surgical procedures were collected prior to the intervention (January 1, 2017 to March 31, 2018) and after implementation (April 1, 2018 to October 31, 2018). Results: A total of 355 cases (229 pre-intervention group, 126 post-intervention group) met the inclusion criteria; the two groups were comparable with respect to all the key parameters except the procedure type and use of endoscopy. Multivariable logistic regression modeling was utilized to evaluate the effects of the stakeholder engagement intervention while adjusting for potential confounders. The incidence of colorectal SSIs was substantially lower after the intervention (2.78% vs. 8.73%, p = 0.02). This reduction was robust to adjustment for covariates in regression modeling (p = 0.04). Conclusions: Informed stakeholder engagement helped bring cohesion to the inherently fragmented elements of the care delivery model and was associated with decreased incidence of colorectal SSIs.
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Affiliation(s)
- Abdelghaffar K Salous
- Department of General Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Christopher R D'Adamo
- Department of Epidemiology and Public Health and Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jamie Rubin
- Department of General Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Joshua Zweigle
- Trinity Medical Sciences University, Roswell, Georgia, USA
| | | | | | - Madison Lannom
- Trinity Medical Sciences University, Roswell, Georgia, USA
| | | | - JoAnn Coleman
- Department of General Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Vanita Ahuja
- Department of General Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Bowker SL, Stelfox HT, Bagshaw SM. Critical Care Strategic Clinical Network: Information infrastructure ensures a learning health system. CMAJ 2020; 191:S22-S23. [PMID: 31801758 DOI: 10.1503/cmaj.190578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Samantha L Bowker
- Critical Care Strategic Clinical Network (Bowker, Stelfox, Bagshaw), Alberta Health Services; Department of Critical Care Medicine, Faculty of Medicine and Dentistry (Bowker, Bagshaw), University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alta
| | - Henry T Stelfox
- Critical Care Strategic Clinical Network (Bowker, Stelfox, Bagshaw), Alberta Health Services; Department of Critical Care Medicine, Faculty of Medicine and Dentistry (Bowker, Bagshaw), University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alta
| | - Sean M Bagshaw
- Critical Care Strategic Clinical Network (Bowker, Stelfox, Bagshaw), Alberta Health Services; Department of Critical Care Medicine, Faculty of Medicine and Dentistry (Bowker, Bagshaw), University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alta.
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Fiest KM, Krewulak KD, Sept BG, Spence KL, Davidson JE, Ely EW, Soo A, Stelfox HT. A study protocol for a randomized controlled trial of family-partnered delirium prevention, detection, and management in critically ill adults: the ACTIVATE study. BMC Health Serv Res 2020; 20:453. [PMID: 32448187 PMCID: PMC7245836 DOI: 10.1186/s12913-020-05281-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 12/24/2022] Open
Abstract
Background Delirium is very common in critically ill patients admitted to the intensive care unit (ICU) and results in negative long-term outcomes. Family members are also at risk of long-term complications, including depression and anxiety. Family members are frequently at the bedside and want to be engaged; they know the patient best and may notice subtle changes prior to the care team. By engaging family members in delirium care, we may be able to improve both patient and family outcomes by identifying delirium sooner and capacitating family members in care. Methods The primary aim of this study is to determine the effect of family-administered delirium prevention, detection, and management in critically ill patients on family member symptoms of depression and anxiety, compared to usual care. One-hundred and ninety-eight patient-family dyads will be recruited from four medical-surgical ICUs in Calgary, Canada. Dyads will be randomized 1:1 to the intervention or control group. The intervention consists of family-partnered delirium prevention, detection, and management, while the control group will receive usual care. Delirium, depression, and anxiety will be measured using validated tools, and participants will be followed for 1- and 3-months post-ICU discharge. All analyses will be intention-to-treat and adjusted for pre-identified covariates. Ethical approval has been granted by the University of Calgary Conjoint Health Research Ethics Board (REB19–1000) and the trial registered. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist. Discussion Critically ill patients are frequently unable to participate in their own care, and partnering with their family members is particularly important for improving experiences and outcomes of care for both patients and families. Trial registration Registered September 23, 2019 on Clinicaltrials.gov NCT04099472.
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Affiliation(s)
- Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Canada. .,Department of Community Health Sciences & O'Brien Institute of Public Health, University of Calgary, Calgary, Canada. .,Department of Psychiatry & Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Canada
| | - Bonnie G Sept
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Canada
| | - Krista L Spence
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Canada
| | - Judy E Davidson
- Department of Psychiatry, UC San Diego School of Medicine, San Diego, California, USA
| | - E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (VA GRECC), Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Canada.,Department of Community Health Sciences & O'Brien Institute of Public Health, University of Calgary, Calgary, Canada.,Department of Psychiatry & Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
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Abstract
PURPOSE OF REVIEW To focus on the missing link between accuracy and precision of monitoring devices and effective implementation of therapeutic strategies. RECENT FINDINGS Haemodynamic monitoring is generally considered to be an essential part of intensive care medicine. However, randomized controlled trials fail to demonstrate improved outcome unequivocally as a result of hemodynamic monitoring. This absence of solid proof renders doctors to hesitance to apply haemodynamic monitoring in clinical practise. Profound understanding of the underlying mechanisms, adequate patient selection and timing, meaningful representation and software-supported interpretation of data all play an important role. Furthermore, protocol adherence and human behaviour seem to form the often missing link between a solid physiologic principle and clinically relevant outcome. Introduction of haemodynamic monitoring should therefore not be limited to theoretical and practical issues, but also involve integration strategies. By learning from others, we might be able to implement haemodynamic monitoring in such a way that it has potential to modify the course of a disease. SUMMARY The clinical success of haemodynamic monitoring goes far beyond accuracy and precision of monitoring devices. Understanding of the factors influencing the effective implementation of therapeutic strategies plays an important role in the meaningful introduction of haemodynamic monitoring.
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Parsons Leigh J, Petersen J, de Grood C, Whalen-Browne L, Niven D, Stelfox HT. Mapping structure, process and outcomes in the removal of low-value care practices in Canadian intensive care units: protocol for a mixed-methods exploratory study. BMJ Open 2019; 9:e033333. [PMID: 31848173 PMCID: PMC6937030 DOI: 10.1136/bmjopen-2019-033333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The challenge of implementing best evidence into clinical practice is a major problem in modern healthcare that can result in ineffective, inefficient and unsafe care. There is a growing body of literature which suggests that the removal or reduction of low-value care practices (ie, deadoption) is integral to the delivery of high-quality care and the sustainability of our healthcare system. However, currently very little is known about deadoption practices in Canada. We propose to map the current state of deadoption in Canadian intensive care units (ICUs). A key deliverable of this work will include development of an inventory of barriers, facilitators and potential implementation strategies for guiding the deadoption efforts. METHODS AND ANALYSIS We will use Canadian adult general systems ICUs as our laboratory of investigation and employ a two-phased sequential exploratory mixed-methods approach: (1) semi-structured interviews with critical care stakeholders to develop an understanding of the structure (ie, healthcare context), process (ie, actions and events in healthcare) and outcomes (ie, effects on health status, quality, knowledge or behaviour) of deadoption (phase I) and (2) surveys with a broader sample of critical care stakeholders to further identify important barriers and facilitators, as well as potential implementation strategies (phase II). Interview data will be analysed through qualitative content analysis and survey data will be analysed through quantitative analyses to identify top barriers and facilitators, as well as top rated strategies. ETHICS AND DISSEMINATION Ethical approval has been obtained through the University of Calgary Research Ethics Board (REB 17-2153). Participants involved will have the opportunity to provide feedback on the final written reports to support accurate representation of the data. The findings of this study will be disseminated through peer-reviewed publications and oral presentations with critical care stakeholders across Canada. Patient and family partners will receive an executive summary of the findings.
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Affiliation(s)
- Jeanna Parsons Leigh
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jennie Petersen
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Chloe de Grood
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Liam Whalen-Browne
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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14
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The Mixed-Method 5W2D Approach for Health System Stakeholders Analysis in Quality of Care: An Application to the Moroccan Context. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16162899. [PMID: 31412655 PMCID: PMC6719162 DOI: 10.3390/ijerph16162899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 01/06/2023]
Abstract
(1) Background: Quality of care (QC) is not only about satisfying patients, but also about satisfying the various health system stakeholders (HSS). This makes it a complex and difficult objective to achieve. This study aims at proposing a methodological framework for identifying HSS, prioritizing them in QC, and analyzing their interrelationships. (2) Methods: The proposed framework is the mixed-method 5W2D approach, which uses a combination of three basic methods: the 5W questioning technique (What, Who, Why, Where, and When), the Delphi method, and the Decision making trial and evaluation laboratory (DEMATEL) technique. It consists of three interdependent phases. First of all, a preliminary list of HSS is established based on a systematic literature review, which is then projected and adapted to the national context using the 5W questioning technique. Secondly, the identified HSS are classified in order according to their influence and impact on QC by employing Delphi method. Thirdly, the interrelationships between HSS are determined and analyzed by applying DEMATEL technique. An application of 5W2D is conducted in the Moroccan context as its health system involves a wide range of stakeholders. (3) Results: Results defined 17 groups of HSS, whose prioritization led to three groups that are at the core of the health system: patients and their families, health personnel, and government. Roles and expectations of these groups regarding QC are divergent and contradictory, which require making trade-offs. The findings of this study intend to guide the development of inclusive strategies and policies that involve key stakeholders for QC assessment and improvement.
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15
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Toward a Unified Integration Approach: Uniting Diverse Primary Care Strategies Under the Primary Care Behavioral Health (PCBH) Model. J Clin Psychol Med Settings 2019; 25:187-196. [PMID: 29234927 DOI: 10.1007/s10880-017-9516-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Primary care continues to be at the center of health care transformation. The Primary Care Behavioral Health (PCBH) model of service delivery includes patient-centered care delivery strategies that can improve clinical outcomes, cost, and patient and primary care provider satisfaction with services. This article reviews the link between the PCBH model of service delivery and health care services quality improvement, and provides guidance for initiating PCBH model clinical pathways for patients facing depression, chronic pain, alcohol misuse, obesity, insomnia, and social barriers to health.
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16
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Sauro K, Bagshaw SM, Niven D, Soo A, Brundin-Mather R, Parsons Leigh J, Cook DJ, Stelfox HT. Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study. BMJ Open 2019; 9:e024159. [PMID: 30878979 PMCID: PMC6429967 DOI: 10.1136/bmjopen-2018-024159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices. DESIGN (1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers. SETTING Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers. PARTICIPANTS Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs. MAIN OUTCOME MEASURES (1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices. RESULTS LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively). CONCLUSIONS Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.
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Affiliation(s)
- Khara Sauro
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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17
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A multicentre controlled pre-post trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients. Intensive Care Med 2019; 45:211-222. [PMID: 30707246 DOI: 10.1007/s00134-019-05532-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/14/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To test whether a multicomponent intervention would increase the use of low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis in critically ill patients and change patient outcomes and healthcare utilization. METHODS Controlled pre-post trial of 12,342 adults admitted to 11 ICUs (five intervention, six control) May 1, 2015 to April 30, 2017 with no contraindication to pharmacological prophylaxis and an ICU stay longer than 24 h. Models were developed to examine temporal changes in ICU VTE prophylaxis (primary outcome), VTE, major bleeding, heparin-induced thrombocytopenia (HIT), death and hospital costs. RESULTS The use of LMWH increased from 45.9% to 78.3% of patient days in the intervention group and from 37.9% to 53.3% in the control group, an absolute increase difference of 17.0% (32.4% vs. 15.4%, p = 0.001). Changes in the administration of UFH were inversely related to those of LMWH. There were no significant differences in the adjusted odds of VTE (ratio of odds ratios [rOR] 1.13, 95% CI 0.51-2.46) or major bleeding (rOR 1.22, 95% CI 0.97-1.54) post-implementation of the intervention (compared to pre-implementation) between the intervention group and the control group. HIT was uncommon in both groups (n = 20 patients). There were no significant changes for ICU and hospital mortality, length of stay and costs. Results were similar when stratified according to reason for ICU admission, patient weight and kidney function. CONCLUSIONS A multicomponent intervention changed practice, but not clinical and economic outcomes. The benefit of implementing LMWH for VTE prophylaxis under real-world conditions is uncertain.
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18
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Spackman E, Clement F, Allan GM, Bell CM, Bjerre LM, Blackburn DF, Blais R, Hazlewood G, Klarenbach S, Nicolle LE, Persaud N, Alessi-Severini S, Tierney M, Wijeysundera HC, Manns B. Developing key performance indicators for prescription medication systems. PLoS One 2019; 14:e0210794. [PMID: 30645647 PMCID: PMC6333341 DOI: 10.1371/journal.pone.0210794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/02/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To develop key performance indicators that evaluate the effectiveness of a prescription medication system. METHODS A modified RAND/UCLA appropriateness method was used to develop key performance indicators (KPIs) for a prescription medication system. A broad list of potential KPIs was compiled. A multidisciplinary group composed of 21 experts rated the potential KPIs. A face-to-face meeting was held following the first rating exercise to discuss each potential KPI individually. The expert panel undertook a final rating of KPIs. The final set of KPIs were those indicators where at least 80 percent of experts rated the indicator highly i.e. rating of ≥ 7 on a scale from 1 to 9. RESULTS 292 KPIs were identified from the published literature. After removing duplicates and combining similar indicators 71 KPIs were included. The final ranking resulted in six indicators being ranked 7 or higher by 80% of the respondents and an additional seven indicators being ranked 7 or higher by ≥70 but ≤80% of respondents. The six selected indicators include four specific disease areas, measure structural and process aspects of health service delivery, and assessed three of the domains of healthcare quality: efficiency, effectiveness, and safety. CONCLUSIONS These indicators are recommended as a starting point to assess the current performance of prescription medication systems. Consideration should be given to developing indicators in additional disease areas as well as indicators that measure the domains of timeliness and patient-centeredness. Future work should focus on the feasibility of measuring these indicators.
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Affiliation(s)
- Eldon Spackman
- Department of Community Health Sciences and O’Brien Institute of Public Health, Calgary, Alberta, Canada
| | - Fiona Clement
- Department of Community Health Sciences and O’Brien Institute of Public Health, Calgary, Alberta, Canada
| | - G. Michael Allan
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Chaim M. Bell
- Department of Medicine, Sinai Health System and University of Toronto, Toronto, Ontario, Canada
| | - Lise M. Bjerre
- Department of Family Medicine, Bruyère Research Institute, and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dave F. Blackburn
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Régis Blais
- School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Glen Hazlewood
- Department of Community Health Sciences and O’Brien Institute of Public Health, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Scott Klarenbach
- Department of Medicine University of Alberta, Edmonton, Alberta, Canada
| | - Lindsay E. Nicolle
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nav Persaud
- St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Silvia Alessi-Severini
- College of Pharmacy and Manitoba Centre for Health Policy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mike Tierney
- Independent Researcher, Ottawa, Onttario, Canada
| | - Harindra C. Wijeysundera
- Canadian Agency for Drugs and Technology in Health (CADTH), Ottawa, Ontario, Canada
- Schulich Heart Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Braden Manns
- Department of Community Health Sciences and O’Brien Institute of Public Health, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative. J Crit Care 2018; 50:111-117. [PMID: 30529419 DOI: 10.1016/j.jcrc.2018.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/05/2018] [Accepted: 11/21/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients. MATERIALS AND METHODS This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach. RESULTS Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group. CONCLUSIONS The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives.
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20
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Perspectives on strained intensive care unit capacity: A survey of critical care professionals. PLoS One 2018; 13:e0201524. [PMID: 30133479 PMCID: PMC6104911 DOI: 10.1371/journal.pone.0201524] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 06/18/2018] [Indexed: 01/09/2023] Open
Abstract
Background Strained intensive care unit (ICU) capacity represents a supply-demand mismatch in ICU care. Limited data have explored health care worker (HCW) perceptions of strain. Methods Cross-sectional survey of HCW across 16 Alberta ICUs. A web-based questionnaire captured data on demographics, strain definition, and sources, impact and strategies for management. Results 658 HCW responded (33%; 95%CI, 32–36%), of which 452 were nurses (69%), 128 allied health (19%), 45 physicians (7%) and 33 administrators (5%). Participants (agreed/strongly agreed: 94%) reported that strain was best defined as “a time-varying imbalance between the supply of available beds, staff and/or resources and the demand to provide high-quality care for patients who may become or who are critically ill”; while some recommended defining “high-quality care”, integrating “safety”, and families in the definition. Participants reported significant contributors to strain were: “inability to discharge ICU patients due to lack of available ward beds” (97%); “increases in the volume” (89%); and “acuity and complexity of patients requiring ICU support” (88%). Strain was perceived to “increase stress levels in health care providers” (98%); and “burnout in health care providers” (96%). The highest ranked strategies were: “have more consistent and better goals-of-care conversations with patients/families outside of ICU” (95%); and “increase non-acute care beds” (92%). Interpretation Strain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies “outside” of ICU settings were priorities for managing strain.
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21
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McKenzie E, Potestio ML, Boyd JM, Niven DJ, Brundin-Mather R, Bagshaw SM, Stelfox HT. Reconciling patient and provider priorities for improving the care of critically ill patients: A consensus method and qualitative analysis of decision making. Health Expect 2017; 20:1367-1374. [PMID: 28561887 PMCID: PMC5689241 DOI: 10.1111/hex.12576] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2017] [Indexed: 12/21/2022] Open
Abstract
Background Providers have traditionally established priorities for quality improvement; however, patients and their family members have recently become involved in priority setting. Little is known about how to reconcile priorities of different stakeholder groups into a single prioritized list that is actionable for organizations. Objective To describe the decision‐making process for establishing consensus used by a diverse panel of stakeholders to reconcile two sets of quality improvement priorities (provider/decision maker priorities n=9; patient/family priorities n=19) into a single prioritized list. Design We employed a modified Delphi process with a diverse group of panellists to reconcile priorities for improving care of critically ill patients in the intensive care unit (ICU). Proceedings were audio‐recorded, transcribed and analysed using qualitative content analysis to explore the decision‐making process for establishing consensus. Setting and participants Nine panellists including three providers, three decision makers and three family members of previously critically ill patients. Results Panellists rated and revised 28 priorities over three rounds of review and reached consensus on the “Top 5” priorities for quality improvement: transition of patient care from ICU to hospital ward; family presence and effective communication; delirium screening and management; early mobilization; and transition of patient care between ICU providers. Four themes were identified as important for establishing consensus: storytelling (sharing personal experiences), amalgamating priorities (negotiating priority scope), considering evaluation criteria and having a priority champion. Conclusions Our study demonstrates the feasibility of incorporating families of patients into a multistakeholder prioritization exercise. The approach described can be used to guide consensus building and reconcile priorities of diverse stakeholder groups.
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Affiliation(s)
| | - Melissa L Potestio
- Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Jamie M Boyd
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,W21C Research and Innovation Centre, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Sean M Bagshaw
- Department of Critical Care, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Calgary, AB, Canada
| | - Henry T Stelfox
- Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
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22
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Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study. Crit Care Med 2017; 45:e347-e356. [PMID: 27635769 DOI: 10.1097/ccm.0000000000002093] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain. DESIGN Qualitative study using a conventional thematic analysis. SETTING Nine ICUs across Alberta, Canada. SUBJECTS Nineteen focus groups (n = 122 participants). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization"). CONCLUSIONS Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.
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Stahl BC, Wakunuma K, Rainey S, Hansen C. Improving brain computer interface research through user involvement - The transformative potential of integrating civil society organisations in research projects. PLoS One 2017; 12:e0171818. [PMID: 28207882 PMCID: PMC5313172 DOI: 10.1371/journal.pone.0171818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 01/26/2017] [Indexed: 11/18/2022] Open
Abstract
Research on Brain Computer Interfaces (BCI) often aims to provide solutions for vulnerable populations, such as individuals with diseases, conditions or disabilities that keep them from using traditional interfaces. Such research thereby contributes to the public good. This contribution to the public good corresponds to a broader drive of research and funding policy that focuses on promoting beneficial societal impact. One way of achieving this is to engage with the public. In practical terms this can be done by integrating civil society organisations (CSOs) in research. The open question at the heart of this paper is whether and how such CSO integration can transform the research and contribute to the public good. To answer this question the paper describes five detailed qualitative case studies of research projects including CSOs. The paper finds that transformative impact of CSO integration is possible but by no means assured. It provides recommendations on how transformative impact can be promoted.
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Affiliation(s)
- Bernd Carsten Stahl
- Centre for Computing and Social Responsibility, School of Computer Science and Informatics, De Montfort University, Leicester, United Kingdom
| | - Kutoma Wakunuma
- Centre for Computing and Social Responsibility, School of Computer Science and Informatics, De Montfort University, Leicester, United Kingdom
| | - Stephen Rainey
- Centre for Computing and Social Responsibility, School of Computer Science and Informatics, De Montfort University, Leicester, United Kingdom
| | - Christian Hansen
- Centre for Computing and Social Responsibility, School of Computer Science and Informatics, De Montfort University, Leicester, United Kingdom
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Gutiérrez-Ibarluzea I, Chiumente M, Dauben HP. The Life Cycle of Health Technologies. Challenges and Ways Forward. Front Pharmacol 2017; 8:14. [PMID: 28174538 PMCID: PMC5258694 DOI: 10.3389/fphar.2017.00014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 01/09/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Iñaki Gutiérrez-Ibarluzea
- Osteba, Basque Office for Health Technology Assessment (HTA), Ministry for Health, Basque Government Vitoria-Gasteiz, Spain
| | - Marco Chiumente
- Societá Italiana di Farmacia Clinica e Terapia (SIFaCT) - Italian Society of Clinical Pharmacy and Therapeutics Milan, Italy
| | - Hans-Peter Dauben
- German Agency for Health Technology Assessment (DAHTA), Deutsches Institut für Medizinische Dokumentation und Information (DIMDI) Cologne, Germany
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Parsons Leigh J, Niven DJ, Boyd JM, Stelfox HT. Developing a framework to guide the de-adoption of low-value clinical practices in acute care medicine: a study protocol. BMC Health Serv Res 2017; 17:54. [PMID: 28103931 PMCID: PMC5247804 DOI: 10.1186/s12913-017-2005-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare systems have difficulty incorporating scientific evidence into clinical practice, especially when science suggests that existing clinical practices are of low-value (e.g. ineffective or harmful to patients). While a number of lists outlining low-value practices in acute care medicine currently exist, less is known about how best to initiate and sustain the removal of low-value clinical practices (i.e. de-adoption). This study will develop a comprehensive list of barriers and facilitators to the de-adoption of low-value clinical practices in acute care facilities to inform the development of a framework to guide the de-adoption process. METHODS The proposed project is a multi-stage mixed methods study to develop a framework to guide the de-adoption of low-value clinical practices in acute care medicine that will be tested in a representative sample of acute care settings in Alberta, Canada. Specifically, we will: 1) conduct a systematic review of the de-adoption literature to identify published barriers and facilitators to the de-adoption of low-value clinical practices in acute care medicine and any associated interventions proposed (Phase one); 2) conduct focus groups with acute care stakeholders to identify important themes not published in the literature and obtain a comprehensive appreciation of stakeholder perspectives (Phase two); 3) extend the generalizability of focus group findings by conducting individual stakeholder surveys with a representative sample of acute care providers throughout the province to determine which barriers and facilitators identified in Phases one and two are most relevant in their clinical setting (Phase three). Identified barriers and facilitators will be catalogued and integrated with targeted interventions in a framework to guide the process of de-adoption in each of four targeted areas of acute care medicine (Emergency Medicine, Cardiovascular Health and Stroke, Surgery and Critical Care Medicine). Analyses will be descriptive using a combination of qualitative and quantitative analyses. DISCUSSION There is a growing body of literature suggesting that the de-adoption of ineffective or harmful practices from patient care is integral to the delivery of high quality care and healthcare sustainability. The framework developed in this study will map barriers and facilitators to de-adoption to the most appropriate interventions, allowing stakeholders to effectively initiate, execute and sustain this process in an evidence-based manner.
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Affiliation(s)
- Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada. .,Alberta Health Services, Alberta, Canada. .,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Jamie M Boyd
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
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26
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Rameau A, de With E, Boerma EC. Passive leg raise testing effectively reduces fluid administration in septic shock after correction of non-compliance to test results. Ann Intensive Care 2017; 7:2. [PMID: 28050895 PMCID: PMC5209308 DOI: 10.1186/s13613-016-0225-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 12/08/2016] [Indexed: 11/27/2022] Open
Abstract
Background Fluid resuscitation is considered a cornerstone of shock treatment, but recent data have underlined the potential hazards of fluid overload. The passive leg raise (PLR) test has been introduced as one of many strategies to predict ‘fluid responsiveness.’ The use of PLR testing is applicable to a wide range of clinical situations and has the potential to reduce fluid administration, since PLR testing is based upon (reversible) autotransfusion. Despite these theoretical advantages, data on the net effect on fluid balance as a result of PLR testing remain scarce. Methods We performed a prospective single-center multi-step interventional study in patients with septic shock to evaluate the effect of implementation of PLR testing on the fluid balance (FB) 48 hours after ICU admission. All patients were equipped with a PiCCO® device for pulse contour analysis to guide fluid administration. An increase in stroke volume (SV) ≥ 10% was considered a positive test result. Results Before introduction of PLR testing, 21 patients were prospectively included in period 1 with a median FB of 4.8 [3.3–7.8]L. After an extensive training program, PLR testing was introduced and 20 patients were included in period 2. Median FB was 4.4 [3.3–7.5]L and did not differ from period 1 (p = 0.72). Further analysis revealed that non-compliance to the PLR test result was 44%. These findings were discussed with all ICU doctors and nurses. By consensus, non-compliance to the PLR test result was identified as the main reason for unsuccessful implementation of PLR testing. After this evaluation, 19 patients were included in period 3 under equal conditions as in period 2. In this period, median FB was 3.1 [1.5–4.9]L and significantly reduced in comparison with periods 1 and 2 (p = 0.016 and p = 0.023, respectively). Non-compliance was 9% and significantly lower than in period 2 (p = 0.009). Conclusion Implementation of PLR testing in patients with septic shock reduced fluid administration in the first 48 hours of ICU admission significantly and substantially. To achieve this endpoint, substantial non-compliance of ICU team members had to be addressed. Fluid administration despite a negative PLR test was the most common form of non-compliance. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0225-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arjanne Rameau
- Department of Intensive Care, Medical Centre Leeuwarden, Henrie Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Eldert de With
- Department of Intensive Care, Medical Centre Leeuwarden, Henrie Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Evert Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, Henrie Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
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Rewa OG, Villeneuve PM, Lachance P, Eurich DT, Stelfox HT, Gibney RTN, Hartling L, Featherstone R, Bagshaw SM. Quality indicators of continuous renal replacement therapy (CRRT) care in critically ill patients: a systematic review. Intensive Care Med 2016; 43:750-763. [DOI: 10.1007/s00134-016-4579-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/26/2016] [Indexed: 11/30/2022]
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Walsh TS, Kydonaki K, Antonelli J, Stephen J, Lee RJ, Everingham K, Hanley J, Phillips EC, Uutela K, Peltola P, Cole S, Quasim T, Ruddy J, McDougall M, Davidson A, Rutherford J, Richards J, Weir CJ. Staff education, regular sedation and analgesia quality feedback, and a sedation monitoring technology for improving sedation and analgesia quality for critically ill, mechanically ventilated patients: a cluster randomised trial. THE LANCET RESPIRATORY MEDICINE 2016; 4:807-817. [PMID: 27473760 DOI: 10.1016/s2213-2600(16)30178-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/10/2016] [Accepted: 06/16/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Optimal sedation of patients in intensive care units (ICUs) requires the avoidance of pain, agitation, and unnecessary deep sedation, but these outcomes are challenging to achieve. Excessive sedation can prolong ICU stay, whereas light sedation can increase pain and frightening memories, which are commonly recalled by ICU survivors. We aimed to assess the effectiveness of three interventions to improve sedation and analgesia quality: an online education programme; regular feedback of sedation-analgesia quality data; and use of a novel sedation-monitoring technology (the Responsiveness Index [RI]). METHODS We did a cluster randomised trial in eight ICUs, which were randomly allocated to receive education alone (two ICUs), education plus sedation-analgesia quality feedback (two ICUs), education plus RI monitoring technology (two ICUs), or all three interventions (two ICUs). Randomisation was done with computer-generated random permuted blocks, stratified according to recruitment start date. A 45 week baseline period was followed by a 45 week intervention period, separated by an 8 week implementation period in which the interventions were introduced. ICU and research staff were not masked to study group assignment during the intervention period. All mechanically ventilated patients were potentially eligible. We assessed patients' sedation-analgesia quality for each 12 h period of nursing care, and sedation-related adverse events daily. Our primary outcome was the proportion of care periods with optimal sedation-analgesia, defined as being free from excessive sedation, agitation, poor limb relaxation, and poor ventilator synchronisation. Analysis used multilevel generalised linear mixed modelling to explore intervention effects in a single model taking clustering and patient-level factors into account. A concurrent mixed-methods process evaluation was undertaken to help understand the trial findings. The trial is registered with ClinicalTrials.gov, number NCT01634451. FINDINGS Between June 1, 2012, and Dec 31, 2014, we included 881 patients (9187 care periods) during the baseline period and 591 patients (6947 care periods) during the intervention period. During the baseline period, optimal sedation-analgesia was present for 5150 (56%) care periods. We found a significant improvement in optimal sedation-analgesia with RI monitoring (odds ratio [OR] 1·44 [95% CI 1·07-1·95]; p=0·017), which was mainly due to increased periods free from excessive sedation (OR 1·59 [1·09-2·31]) and poor ventilator synchronisation (OR 1·55 [1·05-2·30]). However, more patients experienced sedation-related adverse events (OR 1·91 [1·02-3·58]). We found no improvement in overall optimal sedation-analgesia with education (OR 1·13 [95% CI 0·86-1·48]), but fewer patients experienced sedation-related adverse events (OR 0·56 [0·32-0·99]). The sedation-analgesia quality data feedback did not improve quality (OR 0·74 [95% CI 0·54-1·00]) or sedation-related adverse events (OR 1·15 [0·61-2·15]). The process evaluation suggested many clinicians found the RI monitoring useful, but it was often not used for decision making as intended. Education was valued and considered useful by staff. By contrast, sedation-analgesia quality feedback was poorly understood and thought to lack relevance to bedside nursing practice. INTERPRETATION Combination of RI monitoring and online education has the potential to improve sedation-analgesia quality and patient safety in mechanically ventilated ICU patients. The RI monitoring seemed to improve sedation-analgesia quality, but inconsistent adoption by bedside nurses limited its impact. The online education programme resulted in a clinically relevant improvement in patient safety and was valued by nurses, but any changes to behaviours did not seem to alter other measures of sedation-analgesia quality. Providing sedation-analgesia quality feedback to ICUs did not appear to improve any quality metrics, probably because staff did not think it relevant to bedside practice. FUNDING Chief Scientist Office, Scotland; GE Healthcare.
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Affiliation(s)
- Timothy S Walsh
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, Scotland, UK.
| | - Kalliopi Kydonaki
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, Scotland, UK; Edinburgh Napier University, Edinburgh, Scotland, UK
| | - Jean Antonelli
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, Scotland, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, Scotland, UK
| | - Robert J Lee
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, UK
| | - Kirsty Everingham
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, Scotland, UK
| | - Janet Hanley
- Edinburgh Napier University, Edinburgh, Scotland, UK; Edinburgh Health Services Research Unit, Edinburgh, Scotland, UK
| | - Emma C Phillips
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, Scotland, UK
| | - Kimmo Uutela
- GE Healthcare Finland Oy, Kuortaneenkatu 2, 00510 Helsinki, Finland
| | - Petra Peltola
- GE Healthcare Finland Oy, Kuortaneenkatu 2, 00510 Helsinki, Finland
| | - Stephen Cole
- Department of Anaesthetics, Ninewells Hospital, NHS Tayside, Scotland, UK
| | - Tara Quasim
- University Department of Anaesthetics, Glasgow University, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - James Ruddy
- Department of Anaesthetics, Monklands Hospital, NHS Lanarkshire, Scotland, UK
| | - Marcia McDougall
- Department of Anaesthetics, Victoria Hospital, Kirkcaldy, NHS Fife, Scotland, UK
| | - Alan Davidson
- Department of Anaesthetics, Victoria Infirmary, NHS GGC, Glasgow, Scotland, UK
| | - John Rutherford
- Department of Anaesthetics, Dumfries and Galloway Royal Infirmary, NHS Dumfries and Galloway, Scotland, UK
| | - Jonathan Richards
- Department of Anaesthetics, Forth Valley Royal Hospital, NHS Forth Valley, Scotland, UK
| | - Christopher J Weir
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, UK; Edinburgh Health Services Research Unit, Edinburgh, Scotland, UK
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