Telemedicine in the intensive care unit environment—A survey of the attitudes and perspectives of critical care clinicians

Purpose

This study was conducted to assess the preimplementation knowledge and perceptions of intensive care unit (ICU) clinicians regarding the ability of telemedicine in the ICU environment (Tele-ICU) to address challenges resulting from the shortages of experienced critical care human resources and the drive to improve quality of care.

Methods

An online survey was administered to clinicians from a Canadian multisite critical care department. Qualitative and quantitative analyses were undertaken to identify key positive and negative themes.

Results

The overall self-rated knowledge about Tele-ICU was low, with significant uncertainty particularly related to the novelty of the technology, lack of widespread existing implementations, and insufficient education. A significant degree of skepticism was expressed regarding the ability of Tele-ICU to address the challenges of staff shortages and quality of care.

Conclusions

Significant uncertainty and skepticism were expressed by critical care clinicians regarding the ability of Tele-ICU to address the challenges of human resource limitation and the delivery of quality care. This suggests the need for further research and education of system impact beyond patient outcomes related to this new technology.     

Evaluation of a vancomycin dosing nomogram based on the Modification of Diet in Renal Disease equation in intensive care unit patients

Purpose

The purpose of the study is to evaluate the effectiveness of a vancomycin nomogram using actual body weight and the Modification of Diet in Renal Disease equation to estimate renal function in intensive care unit patients.

Methods

Retrospective evaluation (preimplementation group, n = 57) was conducted from March 2011 to April 2011. Prospective evaluation was conducted after nomogram implementation (postimplementation group, n = 60) from December 2011 to February 2012.

Results

The percentage of patients with an initial vancomycin trough concentration 15 μg/mL or higher increased in the postimplementation group as compared with the preimplementation group (72% vs 39%, P = .0004). The postimplementation group also demonstrated an increase in the percentage of patients with initial trough concentration between 15 and 20 μg/mL (42% vs 19%, P = .0099), and no statistical difference in the percentage of patients with an initial trough greater than 20 μg/mL (30% vs 19%, P = .2041). There was no difference in nephrotoxicity in the postimplementation group compared with the preimplementation group (18% vs 17.5%, P = 1.0).

Conclusion

Use of a vancomycin nomogram increased the percentage of initial vancomycin trough concentrations 15 μg/mL or higher in intensive care unit patients and was not associated with an increased occurrence of nephrotoxicity.     

The impact of an ED-only full-capacity protocol

Objective

The objective of this study was to assess the impact of an emergency department (ED)-only full-capacity protocol and diversion, controlling for patient volumes and other potential confounding factors.

Methods

This was a preintervention and postintervention cohort study using data 12 months before and 12 months after the implementation of the protocol. During the implementation period, attending physicians and charge nurses were educated with clear and simple figures on the criteria for the initiation of the new protocol. A multiple logistic regression model was used to compare ambulance diversion between the 2 periods.

Results

The proportion of days when the ED went on diversion at least once during a 24-hour period was 60.4% during the preimplementation period and 20% in the postimplementation periods (P < .001). In the multivariate logistic regression model, the use of the new protocol was significantly associated with decreased odds of diversion rate in the postimplementation period (odds ratio, 0.32; 95% confidence interval, 0.21-0.48).

Conclusion

Our predivert/full-capacity protocol is a simple and generalizable strategy that can be implemented within the boundaries of the ED and is significantly associated with a decreased diversion rate.     

Implementing a guideline for the request of chest and abdominal x-rays in nontrauma pathologic conditions in an ED

Objective

The purpose of this study is to evaluate the impact of implementing a guideline for the request of chest and abdominal x-ray to reduce unnecessary examinations in nontraumatic pathologic conditions.

Methods

We selected most common chief complaints in nontrauma pathologic conditions at emergency department (ED) and reviewed the available literature to determine the effectiveness of chest and abdominal x-rays for each one. We developed a guideline for the request of x-rays according to the chief complaints, including modulating factors derived from initial clinical evaluation. Guideline implementation was achieved through a multifaceted educational intervention. To evaluate its impact, both in the absolute number and in the adequateness of x-ray requests, we compared data obtained from patients coming to the ED at 2 different time points, October 2004 (preimplementation) and October 2005 (postimplementation).

Results

In the preimplementation period, 52.7% of the patients underwent chest x-rays and 28.0% abdominal x-rays, whereas in the postimplementation period, the proportions decreased to 41.8% and 13.5%, respectively (P < .001 in both cases). The adequateness of x-ray requests improved, as shown by a reduction in the number of inappropriate x-ray examinations (absolute error reduction of 9.2%; 95% confidence interval, 7.7-10.8, and relative error reduction of 59.8%; 95% confidence interval, 49.7-69.8).

Conclusions

In our ED, implementing a specifically designed guideline for the request of chest and abdominal x-ray examinations in nontraumatic pathologic conditions reduced the absolute number of requests and the rate of inappropriate requests.     

A multicenter population-based effectiveness study of teleintensive care unit–directed ventilator rounds demonstrating improved adherence to a protective lung strategy,decreased ventilator duration,and decreased intensive care unit mortality

Purpose of the study

The purpose of the study is to determine if teleintensive care unit (ICU)-directed daily ventilator rounds improved adherence to lung protective ventilation (LPV), reduced ventilator duration ratio (VDR), and ICU mortality ratios.

Method used

A retrospective observational longitudinal quarterly analysis of adherence to low tidal volume LPV (< 7.5 mL/kg predicted body weight; Pao₂/fraction of inspired oxygen < 300), ventilator duration, and ICU mortality ratios (Acute Physiology and Chronic Health Evaluation IV–adjusted). The teleICU practice used Philips (Andover, MA) VISICU eCareManager^TM (Andover, MA) platform, providing ICU care and process improvement.

Results

Before ventilator rounds implementation, there was wide variation in hospital adherence to low tidal volume (29.5 ± 18.2; range 10%-69%). Longitudinal improvement was seen across hospitals in the 3 Qs after implementation, reaching statistical significance by Q3 postimplementation (44.9 ± 15.7; P < .002 by 2-tailed Fisher exact test), maintained at 2 subsequent Qs (48% and 52%; P < .001). Ventilator duration ratio also showed preimplementation variability (1.08 ± .34; range 0.71-1.90). After implementation, absolute and significant mean VDR reduction was observed (0.92 ± .28; − 15.8%, P < .05). Intensive care unit mortality ratio demonstrated longitudinal improvement, reaching significance after the Q3 postimplementation (0.94 vs 0.67; P < .04), and this was sustained in the most recent Q analyzed (0.65; P < .03).

Conclusions

Implementation of teleICU-directed ventilator rounds was associated with improved and durable adherence to LPV and significant reductions in both VDR and ICU mortality.     

Consistency of communication among intensive care unit staff as perceived by family members of patients surviving to discharge

Purpose

We hypothesize that intensive care unit (ICU) families frequently perceive that they have received inconsistent information from staff about their relatives and that these inconsistencies influence abilities to make medical decisions, as well as satisfaction.

Materials and Methods

We performed a prospective cohort study in the neurosciences and medical ICU at a university hospital. One hundred twenty-four family members of adult patients surviving to ICU discharge completed a questionnaire regarding perceptions of inconsistent information.

Results

Of 193 eligible patients, 64.2% had family complete the survey. Thirty-one respondents (25.0%; 95% confidence interval, 7.7) reported at least 1 instance of inconsistent information during their family member's admission, with no difference between the neurosciences ICU (21.5%; 9.3) and the medical ICU (31.1%; 14.1; P = .28). Of those who did receive inconsistent information, 38.7% (95% confidence interval, 18.2) reported multiple episodes and 74.2% (16.3) indicated that episodes occurred within the first 48 hours of admission. These episodes had an adverse effect, with 19.4% (14.7) indicating that they affected satisfaction and 9.7% (11.0) indicating that they made decision making difficult.

Conclusions

Episodes involving inconsistent information from staff as perceived by families may be quite prevalent and may influence decision-making abilities and satisfaction.     

Motivation and job satisfaction of Tele-ICU nurses

Introduction

Although the first tele-ICU has been in existence for more than 12 years, little is known about the work of tele-ICU nurses. This study examines sources of motivation and satisfaction of tele-ICU nurses.

Methods

A total of 50 nurses in 5 tele-ICUs were interviewed about reasons for working as a tele-ICU nurse and sources of satisfaction and dissatisfaction in their job.

Results

Nurses have different motivations to work in the tele-ICU, including the challenges and opportunities for new learning that occur while interacting with clinicians in the tele-ICU and the various ICUs being monitored. Tele-ICU nurses also appreciate the opportunities for teamwork with tele-ICU physicians and nurses. The relationship and interactions with the ICUs is sometimes mentioned as a dissatisfier. Some nurses miss being physically at the bedside, as well as interacting with patients and families.

Conclusion

Most tele-ICU nurses are satisfied with their job. They like the challenge in their work and the opportunity to learn. For some nurses, the transition from a bedside caregiver to an information manager can be difficult. Other nurses have found a balance by working part-time in the tele-ICU and part-time in the ICU.     

Factors Influencing Perceived Effectiveness in Dealing with Self-harming Patients in a Sample of Emergency Department Staff

Background

Past self-harming behavior is one of the most significant predictors of future suicide. Each year in Ireland there are approximately 11,000 presentations of self-harm to emergency departments (EDs) across the country.

Study Objectives

This study examines predictors of perceived personal effectiveness in dealing with self-harming patients as reported by ED staff. The predictors are derived from past research and are influenced by Bandura's Social Cognitive Theory.

Method

One hundred twenty-five ED medical staff (28 doctors and 97 nurses) from five EDs in the West and South of Ireland completed a questionnaire. Predictor variables included in the design, and informed by past research, included knowledge of self-harm and suicidal behavior and confidence in dealing with incidents of self-harm.

Results

Standard multiple regression suggested a statistically significant model fit between the two predictors and the criterion variable, accounting for 24% of total variance. Knowledge and Confidence were significant contributors to perceived personal effectiveness in dealing with self-harming patients.

Conclusions

Little is known regarding specific factors that influence perceived effectiveness in dealing with self-harming patients in the ED setting. These findings have implications for psycho-education and training content for staff. The findings suggest that increasing knowledge of self-harm and confidence in dealing with self-harming patients can lead to more positive perceived personal effectiveness in responding to clients' needs.     

A narrative-based study on communication by family members in intensive care unit

Purpose

This study investigates how informative stories are, as written by patients' families in an intensive care unit (ICU) guest book, in terms of families' emotional responses, needs, perceptions, and satisfaction with the quality of care supplied.

Materials and Methods

Design was retrospective observational. Spontaneously written stories (440), gathered between 2009 and 2011, described experiences of 332 family members and 258 patients. Multivariate information from stories was analyzed using cluster analysis.

Results

Most frequently, stories were written in the form of letters addressed to patients (38%, 168 stories). Family members wrote mainly to give encouragement and to motivate patients to live (34%, 150 stories), expressing love or affection (56%, 245 stories). Feedback to ICU staff was provided in 65 stories, and competence was the most relevant skill recognized (31%, 20 stories). Cluster analysis highlighted links between positive feedback and families' positive emotional responses.

Conclusions

The study suggests that ICU guest books can be an effective and simple means of communication between the family, the patient, and the ICU staff. Families shared thoughts, feelings, or opinions, which were meant to be supportive for the patients or rewarding for the staff.     

Implementing,embedding and integrating self-management support tools for people with long-term conditions in primary care nursing: A qualitative study

Background

An implementation gap exists between policy aspirations for provision and the delivery of self-management support in primary care. An evidence based training and support package using a whole systems approach implemented as part of a randomised controlled trial was delivered to general practice staff. The trial found no effect of the intervention on patient outcomes. This paper explores why self-management support failed to become part of normal practice. We focussed on implementation of tools which capture two key aspects of self-management support – education (guidebooks for patients) and forming collaborative partnerships (a shared decision-making tool).

Objectives

To evaluate the implementation and embedding of self-management support in a United Kingdom primary care setting.

Design

Qualitative semi-structured interviews with primary care professionals.

Settings

12 General Practices in the Northwest of England located within a deprived inner city area.

Participants

Practices were approached 3–6 months after undergoing training in a self-management support approach. A pragmatic sample of 37 members of staff – General Practitioners, nurses, and practice support staff from 12 practices agreed to take part. The analysis is based on interviews with 11 practice nurses and one assistant practitioner; all were female with between 2 and 21 years’ experience of working in general practice.

Methods

A qualitative design involving face-to-face, semi-structured interviews audio-recorded and transcribed. Normalisation Process Theory framework allowed a systematic evaluation of the factors influencing the work required to implement the tools.

Findings

The guidebooks were embedded in daily practice but the shared decision-making tools were not. Guidebooks were considered to enhance patient-centredness and were minimally disruptive. Practice nurses were reluctant to engage with behaviour change discussions. Self-management support was not formulated as a practice priority and there was minimal support for this activity within the practice: it was not auditable; was insufficiently differentiated from existing content and processes of work to value in its own right, and considered too disruptive and time-consuming.

Conclusion

Supporting self-management through the encouragement of lifestyle change was problematic to realise with limited evidence of the development of the needed collaborative partnerships between patients and practitioners required by the ethos of self-management support.     

Hourly Rounding in the Pediatric Emergency Department: Patient and Family Safety and Satisfaction Rounds

Background

Methods of increasing patient and family involvement in and understanding of their medical care are plentiful, and hourly rounding specifically has shown benefit in several clinical settings. Although the approach has shown a variety of advantages in other areas, its use in urgent care pediatric settings is not well described.

Objectives

This study evaluates the institution of patient satisfaction and safety rounding (“hourly rounding”) in the pediatric emergency department (ED) setting.

Methods

Hourly rounding was instituted in a tertiary care, urban pediatric ED using a formal mnemonic, after staff education, training, and observation to ensure standardization of approach. Pre- and postintervention data were collected, including frequency and type of nursing call bell usage, family discharge opinion survey, and vendor-collected survey results.

Results

Two weeks of nursing call bell activation data and 200 pre- and postintervention family discharge opinion surveys were collected, evenly divided between pre- and postimplementation data. Call bell activations prior to and after hourly rounding institution were 102 and 150 respectively, with accidental activations comprising the majority. Additionally, vendor-collected patient satisfaction data were analyzed. There were no changes in patient scoring when pre- and postimplementation data were compared.

Conclusions

This model of hourly rounding shows no measurable improvement in patient satisfaction or provider–patient communication using call bell data, family discharge opinion surveys, or vendor-collected patient satisfaction data. Further studies may be indicated to identify different methods of analyzing the effects of this method, and to examine alternative methods of improving these outcomes in the pediatric ED setting.     

Managing intensive care units: Make LOVE,not war!

Objective

Describe a program set up in a French intensive care unit (ICU) aimed at improving communication inside the team and communication information given to patients and their relatives; explain how those actions can improve communication inside the ICU and ultimately why it could improve patient's outcome.

Design and Methods

Position paper.

Intervention

Progressive implementation of multifaceted quality improvement program.

Results

The program Leadership, Ownership, Values, and Evaluation (LOVE) was developed over 10 years. It was usually well accepted by the members of the team, patients, and relatives, in particular the 24-hour visiting program that was prospectively evaluated. Information and decisions were shared with the patients or more often with the relatives, who became for some of them really “part of the team.” Additional actions such as participation to some of the simplest cares by the families are under investigation. A prospective evaluation of such programs, although difficult to perform, remains probably necessary.

Conclusion

Quality of life within the ICU is based on many factors including a strong and positive leadership, an absolute respect of individuals, and a rigorous evaluation of quality of care, which could influence heavily the quality of life in the ICU for patients, relatives, and health care professionals and facilitate team work. Whether this could really influence outcome remains to be demonstrated.     

Multiprofessional survey of protocol use in the intensive care unit

Purpose

To date, there has been no large multicenter, multiprofessional evaluation of protocol and guideline use in the intensive care unit (ICU). The primary purpose of this study was to describe national availability, development, implementation, and assessment of protocols in ICUs. A secondary objective was to compare perceived utility by ease of use, patient safety, cost containment, and compliance of protocols between nurses, physicians, and pharmacists.

Materials and Methods

The survey was developed and tested for validity by 15 clinicians who identified additional domains of interest. An additional 15 clinicians of the 3 different professions evaluated the survey for relevancy and appropriateness of responses. Three survey experts evaluated survey construction. The survey was uploaded to a Web survey tool and pilot tested for clarity and ease of completion.

Results

The overall response rate for the survey was 18.1% (n = 614). Popular methods of education for protocol implementation included staff meetings (85.3%) and unit-specific in-services (77.7%). Protocols were most often updated when new information was available (40.8%) or every 12 months (17.9%). The most common limitation to development and implementation was limited personnel resources (24.5%) and physicians not wanting to use them (21.3%), respectively. Clinicians indicated that protocols made their job easier and improved cost containment some or most of the time. Sepsis protocols were identified as most useful in promoting patient outcomes by all 3 professions.

Conclusions

The types of protocols available appear to be those assisting with management of high-alert medications. Overcoming the perceived barriers of protocol use within ICUs requires personnel for development and physician support. A better protocol review process may be necessary to assure optimal content, desired outcomes, and consistency with Institute for Safe Medication Practices guidelines.     

Organizational and safety culture in Canadian intensive care units: relationship to size of intensive care unit and physician management model

Purpose

The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture.

Materials and Methods

In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture.

Results

Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = −0.46; P = .03), and teamwork across hospital units (r = −0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture.

Conclusion

Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs.     

Nurse staffing,medical staffing and mortality in Intensive Care: An observational study

Objectives

To investigate whether the size of the workforce (nurses, doctors and support staff) has an impact on the survival chances of critically ill patients both in the intensive care unit (ICU) and in the hospital.

Background

Investigations of intensive care outcomes suggest that some of the variation in patient survival rates might be related to staffing levels and workload, but the evidence is still equivocal.

Data

Information about patients, including the outcome of care (whether the patient lived or died) came from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. An Audit Commission survey of ICUs conducted in 1998 gave information about staffing levels. The merged dataset had information on 65 ICUs and 38,168 patients. This is currently the best available dataset for testing the relationship between staffing and outcomes in UK ICUs.

Design

A cross-sectional, retrospective, risk adjusted observational study.

Methods

Multivariable, multilevel logistic regression.

Outcome Measures

ICU and in-hospital mortality.

Results

After controlling for patient characteristics and workload we found that higher numbers of nurses per bed (odds ratio: 0.90, 95% confidence interval: [0.83, 0.97]) and higher numbers of consultants (0.85, [0.76, 0.95]) were associated with higher survival rates. Further exploration revealed that the number of nurses had the greatest impact on patients at high risk of death (0.98, [0.96, 0.99]) whereas the effect of medical staffing was unchanged across the range of patient acuity (1.00, [0.97, 1.03]). No relationship between patient outcomes and the number of support staff (administrative, clerical, technical and scientific staff) was found. Distinguishing between direct care and supernumerary nurses and restricting the analysis to patients who had been in the unit for more than 8 h made little difference to the results. Separate analysis of in-unit and in-hospital survival showed that the clinical workforce in intensive care had a greater impact on ICU mortality than on hospital mortality which gives the study additional credibility.

Conclusion

This study supports claims that the availability of medical and nursing staff is associated with the survival of critically ill patients and suggests that future studies should focus on the resources of the health care team. The results emphasise the urgent need for a prospective study of staffing levels and the organisation of care in ICUs.     

Professional collegiality and peer monitoring among nursing staff: An ethnographic study

Background

Patient safety and professional self-regulation systems both rely on professional colleagues to hold each other accountable for quality of care.

Objectives

To understand how staff nurses manage variations in practices within the group, and negotiate the rules-in-use for quality of care, collegiality, and accountability.

Design/methods

Ethnographic case study; participant-observation, semi-structured interviews, policy analysis.

Setting

In-patient unit in an urban US teaching hospital.

Results

Explicit acknowledgment of conflicts and practice variations was perceived as risky to group cohesion. The dependence of staff on mutual assistance, and the absence of a system of group practice, led to the practice of “mutual deference”, a strategy of reciprocal tolerance and non-interference that gave wide discretion to each nurse's decisions about care.

Conclusions

Efforts to improve professional accountability will need to address material constraints and the organization of nursing work, as well as communication and leadership skills.     

Overuse of stress ulcer prophylaxis in the critical care setting and beyond

Background

Patients admitted to the intensive care unit (ICU) are susceptible to stress ulcers. We hypothesize that despite recommendations, stress ulcer prophylaxis (SUP) is still overused in the ICU and often continued after resolution of risk factors for bleeding.

Methods

We retrospectively studied all ICU admissions for 4 months. Risk factors for stress ulcer bleeding were collected. Patients were categorized into 4 groups: (1) ≥1 major risk factor; (2) ≥1 minor risk factors; (3) no risk factors; (4) preadmission use of acid-suppressive medication. The rate of SUP was calculated by group during ICU stay, on transfer from the ICU, and at hospital discharge.

Results

Two hundred ten patients were studied. Of all the ICU admissions, 87.1% received SUP. Among patients with no risk factors, 68.1% were placed on prophylaxis on ICU admission; 60.4% continued on treatment upon transfer from the ICU; 31.0% were discharged home on an agent without a new indication.

Conclusions

Although judicious use of SUP in high-risk patients can decrease the incidence of gastrointestinal bleeding, inappropriate use may increase drug reactions, unnecessary hospital costs, and personal monetary burden. Our findings argue for improvement measures to reduce initial inpatient overuse of SUP and to prompt discontinuation before hospital discharge.     

Hospitalist bed management effecting throughput from the emergency department to the intensive care unit

Rationale

Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes.

Objective

To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the “active bed management” (ABM) intervention.

Methods

A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow.

Measurement

Throughput time for patients presenting to the ED requiring ICU admission was analyzed.

Main Results

The ED census was higher during the intervention period as compared with the control period, 17?573 versus 16?148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (±14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant.

Conclusion

Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety.