Enhancing Implementation of Complex Critical Care Interventions through Interprofessional Education

Lung Protective Ventilation Adherence and Outcomes for Patients With COVID-19 Acute Respiratory Distress Syndrome Treated in an Intermediate Care Unit Repurposed to ICU Level of Care

OBJECTIVE

During the COVID-19 pandemic, some centers converted intermediate care units (IMCUs) to COVID-19 ICUs (IMCU/ICUs). In this study, we compared adherence to lung protective ventilation (LPV) and outcomes for patients with COVID-19-related acute respiratory distress syndrome (ARDS) treated in an IMCU/ICU versus preexisting medical ICUs (MICUs).

DESIGN

Retrospective observational study using electronic medical record data.

SETTING

Two academic medical centers from March 2020 to September 2020 (period 1) and October 2020 to May 2021 (period 2), which capture the first two COVID-19 surges in this health system.

PATIENTS

Adults with COVID-19 receiving invasive mechanical ventilation who met ARDS oxygenation criteria (Pao2/Fio2 ≤ 300 mm Hg or Spo2/Fio2 ≤ 315).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We defined LPV adherence as the percent of the first 48 hours of mechanical ventilation that met a restrictive definition of LPV of, tidal volume/predicted body weight (Vt/PBW) less than or equal to 6.5 mL/kg and plateau pressure (Pplat) less than or equal to 30 cm H2o. In an expanded definition, we added that if Pplat is greater than 30 cm H2o, Vt/PBW had to be less than 6.0 mL/kg. Using the restricted definition, period 1 adherence was lower among 133 IMCU/ICU versus 199 MICU patients (92% [95% CI, 50-100] vs. 100% [86-100], p = 0.05). Period 2 adherence was similar between groups (100% [75-100] vs. 95% CI [65-100], p = 0.68). A similar pattern was observed using the expanded definition. For the full study period, the adjusted hazard of death at 90 days was lower in IMCU/ICU versus MICU patients (hazard ratio [HR] 0.73 [95% CI, 0.55-0.99]), whereas ventilator liberation by day 28 was similar between groups (adjusted subdistribution HR 1.09 [95% CI, 0.85-1.39]).

CONCLUSIONS

In patients with COVID-19 ARDS treated in an IMCU/ICU, LPV adherence was similar to, and observed survival better than those treated in preexisting MICUs. With adequate resources, protocols, and staffing, IMCUs provide an effective source of additional ICU capacity for patients with acute respiratory failure.

Assessing the impact of real-time random safety audits through full propensity score matching on reliable data from the clinical information system

BACKGROUND

Evidence-based care processes are not always applied at the bedside in critically ill patients. Numerous studies have assessed the impact of checklists and related strategies on the process of care and patient outcomes. We aimed to evaluate the effects of real-time random safety audits on process-of-care and outcome variables in critical care patients.

METHODS

This prospective study used data from the clinical information system to evaluate the impact of real-time random safety audits targeting 32 safety measures in two intensive care units during a 9-month period. We compared endpoints between patients attended with safety audits and those not attended with safety audits. The primary endpoint was mortality, measured by Cox hazard regression after full propensity-score matching. Secondary endpoints were the impact on adherence to process-of-care measures and on quality indicators.

RESULTS

We included 871 patients; 228 of these were attended in ≥ 1 real-time random safety audits. Safety audits were carried out on 390 patient-days; most improvements in the process of care were observed in safety measures related to mechanical ventilation, renal function and therapies, nutrition, and clinical information system. Although the group of patients attended in safety audits had more severe disease at ICU admission [APACHE II score 21 (16-27) vs. 20 (15-25), p = 0.023]; included a higher proportion of surgical patients [37.3 % vs. 26.4 %, p = 0.003] and a higher proportion of mechanically ventilated patients [72.8 % vs. 40.3 %, p < 0.001]; averaged more days on mechanical ventilation, central venous catheter, and urinary catheter; and had a longer ICU stay [12.5 (5.5-23.3) vs. 2.9 (1.7-5.9), p < 0.001], ICU mortality did not differ significantly between groups (19.3 % vs. 18.8 % in the group without safety rounds). After full propensity-score matching, Cox hazard regression analysis showed real-time random safety audits were associated with a lower risk of mortality throughout the ICU stay (HR 0.31; 95 %CI 0.20-0.47).

CONCLUSIONS

Real-time random safety audits are associated with a reduction in the risk of ICU mortality. Exploiting data from the clinical information system is useful in assessing the impact of them on the care process, quality indicators, and mortality.

Interprofessional Collaboration Between Nurses and Physicians in the Perioperative Period

PURPOSE

To explore nurses' and physicians' experiences of the six dimensions of interprofessional (IP) collaboration when using Goal-Directed Therapy (GDT), and to examine how existing protocols on GDT facilitate the six dimensions of IP collaboration.

DESIGN

A qualitative design using individual semi-structured interviews and participant observations.

METHODS

A secondary analysis of data from participant observation and semi-structured interviews with nurses (n= 23) and physicians (n=12) in three departments of anesthesiology. Observations and interviews were carried out from December 2016 to June 2017. A deductive, qualitative content analysis using the Inter-Professional Activity Classification as a categorization matrix was used to explore interprofessional collaboration as a barrier to implementation. This analysis was supplemented by a text analysis of two protocols.

FINDINGS

Four dimensions were identified to influence IP collaboration: commitment, roles and responsibilities, interdependence, and integration of work practices. Negative factors included hierarchical boundaries, traditional nurse-physician relationship, unclear responsibility, and lack of shared knowledge. Positive factors included physician involvement of nurses in decisions and bedside education. The text-analysis showed a lack of clear directions of specific action and responsibility.

CONCLUSIONS

Commitment and roles and responsibilities were dominant aspects of interprofessional collaboration in this context, causing problems for enhanced collaboration. Lack of clear guidance in the protocols might detract nurses' feelings of responsibility.

Analysis of shared cognitive tasks in the application of non-invasive ventilation to patients with COPD exacerbation

Interprofessional teamwork plays a key role in the uptake of evidence-based interventions, such as noninvasive ventilation (NIV) for patients with exacerbated Chronic Obstructive Pulmonary Disease (COPD). We aimed to identify the shared cognitive tasks in interprofessional teams using NIV for patients with COPD exacerbation. We used a cognitive task analysis approach (CTA) to engage nurses, rapid response team members, respiratory therapists, and physicians involved in the use of NIV to treat patients with COPD exacerbation. Clinicians participated in a semi-structured interview (n = 21) that elicited cognitions needed to treat COPD exacerbation. Three shared cognitive tasks were identified: Complete a thorough assessment, Formulate a care plan, and Continuously monitor patient status. Findings attest to the importance of having access to up-to-date information and expertise necessary to make accurate clinical inferences for patient assessment. Shared understanding of the formulated care plan among all members of the care team was important to its execution. Continuous monitoring was crucial; however, this cognitive task relied on patient assessment skills and ongoing collaboration within the clinical care team. Application of NIV for patients with COPD exacerbation may require enhancing collaboration through nontechnical skills and interprofessional training.

Effect of ICU care bundles on long-term patient-relevant outcomes: a scoping review

OBJECTIVE

Care bundles are considered a key tool to improve bedside quality of care in the intensive care unit (ICU). We explored their effect on long-term patient-relevant outcomes.

DESIGN

Systematic literature search and scoping review.

DATA SOURCES

We searched PubMed, Embase, CINAHL, APA PsycInfo, Web of Science, CDSR and CENTRAL for keywords of intensive care, care bundles, patient-relevant outcomes, and follow-up studies.

ELIGIBILITY CRITERIA

Original articles with patients admitted to adult ICUs assessing bundle implementations and measuring long-term (ie, ICU discharge or later) patient-relevant outcomes (ie, mortality, health-related quality of life (HrQoL), post-intensive care syndrome (PICS), care-related outcomes, adverse events, and social health).

DATA EXTRACTION AND SYNTHESIS

After dual, independent, two-stage selection and charting, eligible records were critically appraised and assessed for bundle type, implementation strategies, and effects on long-term patient-relevant outcomes.

RESULTS

Of 2012 records, 38 met inclusion criteria; 55% (n=21) were before-after studies, 21% (n=8) observational cohort studies, 13% (n=5) randomised controlled trials, and 11% (n=4) had other designs. Bundles pertained to sepsis (n=11), neurocognition (n=6), communication (n=4), early rehabilitation (n=3), pharmacological discontinuation (n=3), ventilation (n=2) or combined bundles (n=9). Almost two-thirds of the studies reported on survival (n=24), 45% (n=17) on care-related outcomes (eg, discharge disposition), and 13% (n=5) of studies on HrQoL. Regarding PICS, 24% (n=9) assessed cognition, 13% (n=5) physical health, and 11% (n=4) mental health, up to 1 year after discharge. The effects of bundles on long-term patient-relevant outcomes was inconclusive, except for a positive effect of sepsis bundles on survival. The inconclusive effects may have been due to the high risk of bias in included studies and the variability in implementation strategies, instruments, and follow-up times.

CONCLUSIONS

There is a need to explore the long-term effects of ICU bundles on HrQoL and PICS. Closing this knowledge gap appears vital to determine if there is long-term patient value of ICU bundles.

Implementing health system improvement: resources and strategies for interprofessional teams

Health system improvement (HSI) is focused on systematic changes to organisational processes and practices to improve the efficient delivery of safe care and quality outcomes. Guidelines that specify how interprofessional teams conduct HSI and knowledge translation are needed. We address this urgent requirement providing health professional teams with resources and strategies to investigate, analyse and implement system-level improvements. HSI encompasses similar, yet different, inter-related activities across a continuum. The continuum spans three categories of activities, such as quality improvement, health management research and translational health management research. A HSI decision making guide and checklist, comprising six-steps, is presented that can be used to select and plan projects. This resource comprises six interconnected steps including, defining the activity, project outcome, aim, use of evidence, appropriate methodology and implementation plan. Each step has been developed focusing on an objective, actions and resources. HSI activities provide a foundation for interprofessional collaboration, allowing multiple professions to create, share and disseminate knowledge for improved healthcare. When planned and executed well, HSI projects assist clinical and corporate staff to make evidence-informed decisions and directions for the benefit of the service, organisation and sector.

Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic: A Qualitative Study

Rationale: The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients with coronavirus disease (COVID-19) ARDS, proning has increased. Understanding the factors influencing this change is important for further expanding and sustaining the use of prone positioning in appropriate clinical settings. Objectives: To characterize factors influencing the implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS. Methods: We conducted a qualitative study using semistructured interviews with 40 intensive care unit (ICU) team members (physicians, nurses, advanced practice providers, respiratory therapists, and physical therapists) working at two academic hospitals. We used the Consolidated Framework for Implementation Research, a widely used implementation science framework outlining important features of implementation, to structure the interview guide and thematic analysis of interviews. Results: ICU clinicians reported that during the COVID-19 pandemic, proning was viewed as standard early therapy for COVID-19 ARDS rather than salvage therapy for refractory hypoxemia. By caring for large volumes of proned patients, clinicians gained increased comfort with proning and now view proning as a low-risk, high-benefit intervention. Within ICUs, adequate numbers of trained staff members, increased team agreement around proning, and the availability of specific equipment (e.g., to limit pressure injuries) facilitated greater proning use. Hospital-level supports included proning teams, centralized educational resources specific to the management of COVID-19 (including a recommendation for prone positioning), and an electronic medical record proning order. Important implementation processes included informal dissemination of best practices through on-the-job learning and team interactions during routine bedside care. Conclusions: The implementation of prone positioning for COVID-19 ARDS took place in the context of evolving clinician viewpoints and ICU team cultures. Proning was facilitated by hospital support and buy-in and leadership from bedside clinicians. The successful implementation of prone positioning during the COVID-19 pandemic may serve as a model for the implementation of other evidence-based therapies in critical care.

Characterizing intensive care unit rounding teams using meta-data from the electronic health record

PURPOSE

Teamwork is an important determinant of outcomes in the intensive care unit (ICU), yet the nature of individual ICU teams remains poorly understood. We examined whether meta-data in the form of digital signatures in the electronic health record (EHR) could be used to identify and characterize ICU teams.

METHODS

We analyzed EHR data from 27 ICUs over one year. We linked intensivist physicians, nurses, and respiratory therapists to individual patients based on selected EHR meta-data. We then characterized ICU teams by their members' overall past experience and shared past experience; and used network analysis to characterize ICUs by their network's density and centralization.

RESULTS

We identified 2327 unique providers and 30,892 unique care teams. Teams varied based on their average team member experience (median and total range: 262.2 shifts, 9.0-706.3) and average shared experience (median and total range: 13.2 shared shifts, 1.0-99.3). ICUs varied based on their network's density (median and total range: 0.12, 0.07-0.23), degree centralization (0.50, 0.35-0.65) and closeness centralization (0.45, 0.11-0.60). In a regression analysis, this variation was only partially explained by readily observable ICU characteristics.

CONCLUSIONS

EHR meta-data can assist in the characterization of ICU teams, potentially providing novel insight into strategies to measure and improve team function in critical care.

Initial Development of an Automated Platform for Assessing Trainee Performance on Case Presentations

Background

Oral case presentation is a crucial skill of physicians and a key component of team-based care. However, consistent and objective assessment and feedback on presentations during training are infrequent.

Objective

To determine the potential value of applying natural language processing, computer software that extracts meaning from text, to transcripts of oral case presentations as a strategy to assess their quality automatically and objectively.

Methods

We transcribed a collection of simulated oral case presentations. The presentations were from eight critical care fellows and one critical care attending. They were instructed to review the medical charts of 11 real intensive care unit patient cases and to audio record themselves, presenting each case as if they were doing so on morning rounds. We then used natural language processing to convert the transcripts from human-readable text into machine-readable numbers. These numbers represent details of the presentation style and content. The distance between the numeric representation of two different transcripts negatively correlates with the similarity of those two transcripts. We ranked fellows on the basis of how similar their presentations were to the attending's presentations.

Results

The 99 presentations included 260 minutes of audio (mean length: 2.6 ± 1.24 min per case). On average, 23.88 ± 2.65 sentences were spoken, and each sentence had 14.10 ± 0.67 words, 3.62 ± 0.15 medical concepts, and 0.75 ± 0.09 medical adjectives. When ranking fellows on the basis of how similar their presentations were to the attending's presentation, we found a gap between the five fellows with the most similar presentations and the three fellows with the least similar presentations (average group similarity scores of 0.62 ± 0.01 and 0.53 ± 0.01, respectively). Rankings were sensitive to whether presentation style or content information were weighted more heavily when calculating transcript similarity.

Conclusion

Natural language processing enabled the ranking of case presentations on the basis of how similar they were to a reference presentation. Although additional work is needed to convert these rankings, and underlying similarity scores, into actionable feedback for trainees, these methods may support new tools for improving medical education.