Insights and advances in multidisciplinary critical care: a review of recent research

Identifying the unique behaviors embedded in the process of interprofessional collaboration in the ICU

Interprofessional collaboration (IPC) is an important aspect of high-quality care in intensive care units (ICUs). The practice of IPC, however, is complex and the components that constitute IPC are not well defined. We sought to identify distinct behaviors embedded in clinician workflow that indicate engagement in the IPC process. We conducted a clinical ethnography in two ICUs in southeastern Michigan. From March 2017 to March 2019, we collected 31 hours of observations and completed 12 separate clinician shadowings and 12 interviews with ICU nurses, physicians, and respiratory therapists. We applied an iterative analytical approach to identify two types of IPC behaviors which we a priori labeled as "enablers" (i.e. the ways clinicians transition into or facilitate collaboration) and "collaborative activities" (i.e. behaviors clinicians use to directly collaborate with other professionals). 18 IPC behaviors were identified - ten "enablers" and eight "collaborative activities." Specifically, the enablers include: active listening, approach, coordinating work, intraprofessional consultation, invitation, nonverbal accessibility, reflexive questioning, sending pages/call, validation, and verbal accessibility. The collaborative activities are: correction, fill in the gap, information exchange, negotiation, providing help, socializing, teaching/training, and troubleshooting. By identifying IPC behaviors embedded in clinician workflow, our results may support more focused assessments of IPC in practice and guide clinicians toward behaviors they can use to engage in the IPC process.

The impact of intensive care unit physician staffing change at a community hospital

Objectives

A high-intensity staffing model has been defined as either mandatory intensivist consultation or a closed intensive care unit in which intensivists manage all aspects of patient care. In the current climate of limited healthcare resources, transitioning to a closed intensive care unit model may lead to significant improvements in patient care and resource utilization.

Methods

This is a single-center, retrospective cohort study of all mechanically ventilated intensive care unit admissions in the pre-intensive care unit closure period of 1 October 2014 to 30 September 2015 as compared with the post-intensive care unit closure period of 1 November 2015 to 31 October 2016. Patient demographics as well as outcome data (duration of mechanical ventilation, length of stay, direct costs, complications, and mortality) were abstracted from the electronic health record. All data were analyzed using descriptive and inferential statistics. Regression analyses were used to adjust outcomes for potential confounders.

Results

A total of 549 mechanically ventilated patients were included in our analysis: 285 patients in the pre-closure cohort and 264 patients in the post-closure cohort. After adjusting for confounders, there was no significant difference in mortality rates between the pre-closure (40.7%) and post-closure (38.6%) groups (adjusted odds ratio = 0.82; 95% confidence interval = 0.56-1.18; p = 0.283). The post-closure cohort was found to have significant reductions in duration of mechanical ventilation (3.71-1.50 days; p < 0.01), intensive care unit length of stay (5.8-2.7 days; p < 0.01), hospital length of stay (10.9-7.3 days; p < 0.01), and direct hospital costs (US $16,197-US $12,731; p = 0.009). Patient complications were also significantly reduced post-intensive care unit closure.

Conclusion

Although a closed intensive care unit model in our analysis did not lead to a statistical difference in mortality, it did demonstrate multiple beneficial outcomes including reduced ventilator duration, decreased intensive care unit and hospital length of stay, fewer patient complications, and reduced direct hospital costs.

Hospital Costs Associated with Sepsis Compared with Other Medical Conditions

Sepsis is a condition that has become a main focus for health care organizations owing to the alarming cost of caring for patients, as well as the disturbing mortality rates, that accompany this condition. Sepsis is one of the costliest conditions billed to all payer groups: Medicare, Medicaid, private insurance, and uninsured patients. Health care organizations have implemented multiple strategies and best practices to improve the outcomes of patients with a diagnosis of sepsis.

Care of patients undergoing weaning from mechanical ventilation in critical care

There are several reasons why mechanical ventilation - the use of an artificial device to assist a patient to breathe - may be initiated, for example to enable general anaesthesia for patients undergoing surgery, and for those with a compromised airway or respiratory failure. It is important that critical care nurses have the skills and knowledge to care for patients who are undergoing weaning from mechanical ventilation. This is to ensure that patients are weaned safely and as soon as possible, to improve their outcomes and avoid an increase in patient mortality and morbidity through complications that can arise such as airway trauma and ventilator-associated pneumonia. Furthermore, there are resource and cost implications of patients not being weaned as soon as possible.

Utility and outcomes of hydroxocobalamin use in smoke inhalation patients

INTRODUCTION

Hydroxocobalamin has been available for use for suspected cyanide toxicity in smoke inhalation patients in the United States since 2006. Our study compares outcomes of patients who received hydroxocobalamin to historical controls who did not.

METHODS

In this retrospective review, patients administered hydroxocobalamin (2008-2014) were compared to historical controls (2002-2008). Patients <18 years, patients who received an alternate antidote, and patients without suspicion of smoke inhalation injury were excluded. Mortality was the primary outcome. Secondary outcomes evaluated were 7-day change in creatinine, culture-proven pneumonia, days on mechanical ventilation, ventilator- free days (VFD), ICU length of stay (ICU LOS), and hospital length of stay (HLOS).

RESULTS

A total of 138 patients in the hydroxocobalamin group and 135 in the control group were identified. Mortality rate was similar between both groups (29% vs. 28%, p=0.90). Hydroxocobalamin was associated with lower pneumonia rate (23% vs. 49%, p<0.01), less ventilator days (4 days vs. 7 days, p<0.01), and increased VFD (20 days vs. 11 days, p=0.01) compared to controls. Shorter ICU LOS (6 days vs. 10 days, p=0.03) and a trend toward lower HLOS (7 day vs. 11 days, p=0.06) were also found in patients who received hydroxocobalamin.

CONCLUSIONS

Routine administration was associated with lower rate of pneumonia, faster liberation from the ventilator, and reductions in intensive care unit stay. Burn centers should consider its empiric use in suspected smoke inhalation patients.

Effect of a 2-tier rapid response system on patient outcome and staff satisfaction

BACKGROUND

Rapid response systems (RRS) have been recommended as a strategy to prevent and treat deterioration in acute care patients. Questions regarding the most effective characteristics of RRS and strategies for implementing these systems remain.

AIMS

The aims of this study were to (i) describe the structures and processes used to implement a 2-tier RRS, (ii) determine the comparative prevalence of deteriorating patients and incidence of unplanned intensive care unit (ICU) admission and cardiac arrest prior to and after implementation of the RRS, and (iii) determine clinician satisfaction with the RRS.

METHOD

A quasi-experimental pre-test, post-test design was used to assess patient related outcomes and clinician satisfaction prior to and after implementation of a 2-tier RRS in a tertiary metropolitan hospital. Primary components of the RRS included an ICU Outreach Nurse and a Rapid Response Team. Prevalence of deteriorating patients was assessed through a point prevalence assessment and chart audit. Incidence of unplanned admission to ICU and cardiac arrests were accessed from routine hospital databases. Clinician satisfaction was measured through surveys.

RESULTS

Prevalence of patients who met medical emergency call criteria without current treatment reduced from 3% prior to RRS implementation to 1% after implementation; a similar reduction from 9% to 3% was identified on chart review. The number of unplanned admissions to ICU increased slightly from 17.4/month prior to RRS implementation to 18.1/month after implementation (p=0.45) while cardiac arrests reduced slightly from 7.5/month to 5.6/month (p=0.22) but neither of these changes were statistically significant. Staff satisfaction with the RRS was generally high.

CONCLUSION

The 2-tier RRS was accessed by staff to assist with care of deteriorating patients in a large, tertiary hospital. High levels of satisfaction have been reported by clinical staff.