Long-term persistence of quality improvements for an intensive care unit communication initiative using the VALUE strategy

Purpose

Communication in the intensive care unit (ICU) is an important component of quality ICU care. In this report, we evaluate the long-term effects of a quality improvement (QI) initiative, based on the VALUE communication strategy, designed to improve communication with family members of critically ill patients.

Materials and Methods

We implemented a multifaceted intervention to improve communication in the ICU and measured processes of care. Quality improvement components included posted VALUE placards, templated progress note inclusive of communication documentation, and a daily rounding checklist prompt. We evaluated care for all patients cared for by the intensivists during three separate 3 week periods, pre, post, and 3 years following the initial intervention.

Results

Care delivery was assessed in 38 patients and their families in the pre-intervention sample, 27 in the post-intervention period, and 41 in follow-up. Process measures of communication showed improvement across the evaluation periods, for example, daily updates increased from pre 62% to post 76% to current 84% of opportunities.

Conclusions

Our evaluation of this quality improvement project suggests persistence and continued improvements in the delivery of measured aspects of ICU family communication. Maintenance with point-of-care-tools may account for some of the persistence and continued improvements.     

A systematic review of teamwork in the intensive care unit: What do we know about teamwork,team tasks,and improvement strategies?

Purpose

Teamwork is essential for ensuring the quality and safety of health care delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research.

Methods

A keyword search of the PubMed database was conducted in February 2013. Keyword combinations focused on 3 areas: (1) teamwork, (2) the ICU, and (3) training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (ie, intradepartment) were selected for inclusion.

Results

Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies.

Conclusions

Team research is burgeoning in the ICU, yet low-hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined, and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.     

Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors

Background

Non-physician advanced practice providers (APPs) such as nurse practitioners and physician assistants are being increasingly utilized as critical care providers in the United States. The objectives of this study were to determine the utilization of APPs in the intensive care units (ICU)s of academic medical centers (AMCs) and to assess the perceptions of critical care fellowship program directors (PDs) regarding the impact of these APPs on fellowship training.

Methods

A cross-sectional national survey questionnaire was distributed to program directors of 331 adult Accreditation Council for Graduate Medical Education-approved critical care fellowship training programs (internal medicine, anesthesiology and surgery) in US AMCs.

Results

We received 124 (37.5%) PD responses. Of these, 81 (65%) respondents indicated that an APP was part of the care team in either the primary ICU or any ICU in which the fellow trained. The majority of respondents reported that patient care was positively affected by APPs with nearly two-thirds of PDs reporting that fellowship training was also positively impacted.

Conclusions

Our survey revealed that APPs are utilized in a large number of US AMCs with critical care training programs. Program director respondents believed that patient care and fellowship training were positively impacted by APPs.     

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.     

Passive decision-making preference is associated with anxiety and depression in relatives of patients in the intensive care unit

Purpose

The objectives were to describe the decision-making preferences of relatives (family members) of patients in intensive care units (ICUs), to determine whether the relatives had symptoms of anxiety and depression while the patients were in the ICU, and to determine whether there was a relationship between the relatives' preferences and symptoms.

Methods

In our observational pilot study of relatives in a quaternary care teaching hospital, we administered the Control Preferences Scale to assess decision-making preferences and the Hospital Anxiety and Depression Scale to determine whether anxiety and depression were present.

Results

Of 50 relatives enrolled in the study, 48 indicated decision-making preferences; 12 (25%) preferred an active role, 28 (58%) preferred to share responsibility with the doctor, and 8 (17%) preferred a passive role. Of the 50 relatives, 21 (42%) had symptoms of anxiety, and 8 (16%) had symptoms of depression. In the groups that preferred an active role, shared role, and passive role, respectively, the anxiety rates were 42%, 25%, and 88% (P = .007), and depression rates were 8%, 11%, and 50% (P = .026).

Conclusions

The relatives who preferred a passive decision-making role were the most likely to be anxious and depressed.     

Limiting life-sustaining treatment in German intensive care units: A multiprofessional survey

Purpose

Deciding about the limitation of life-sustaining treatment (LST) is a major challenge for intensive care medicine. The aim of the study was to investigate the practices and perspectives of German intensive care nurses and physicians on limiting LST.

Methods

We conducted an anonymous, self-administered questionnaire survey among the 268 nurses and 95 physicians on all 10 intensive care units of the Munich University Hospital, Germany.

Results

The response rate was 53%. Of all respondents, 91% reported being confronted with the topic at least once a month. Although all reported limiting cardiopulmonary resuscitation, almost no one reported limiting artificial hydration. Half of nurses and junior physicians felt uncertain about the decision-making process. Junior physicians were most dissatisfied with their training for this task and expressed the highest fear of litigation. Nurses were less satisfied than physicians with the communication process. Both nurses and relatives were not routinely involved in decision making. There is no standardized documentation practice, and many notes are not readily accessible to nurses.

Conclusions

Limiting LST is common in German intensive care units. The major shortcomings are team communication, communication with the patient's family, and documentation of the decision-making process.     

Residents' and nurses' perceptions of team function in the medical intensive care unit

Background

Team-based care is integral to modern intensive care units (ICUs). Trainee physicians (“residents”) serve as core team members who provide direct patient care in academic ICUs. However, little is known about how resident perceptions of ICU team function differ from those of other disciplines. Therefore, we compared residents' perceptions to those of nurses', the other predominant direct caregiver group, in the medical ICU.

Methods

A cross-sectional survey was performed with validated team function scales including presence of a real team, communication quality, collaboration, and coordination. The survey was administered to nurses and residents in medical ICUs in an urban academic medical center. We analyzed differences between nurses and residents both in their responses and in their perceptions of how constructs were interrelated.

Results

Residents felt that the team was more bounded, was more collaborative, and planned its work to a greater degree, but they were less satisfied with communication, compared with nurses. Residents and nurses perceived relationships between team function constructs in very similar ways. Both groups felt that communication openness and collaboration were positively associated but that communication accuracy and timeliness were negatively correlated, revealing an opportunity to improve overall team performance.

Conclusions

We found important differences in the way that ICU nurses and medical trainee physicians, the predominant types of providers caring for the critically ill in academic medical center ICUs, perceive key aspects of team function. These results may be useful to those responsible for administering academic ICUs as well as to residency program directors developing communication- and team-based curricula.     

Medication issues experienced by patients and carers after discharge from the intensive care unit

Purpose

Medication-related problems (MRPs) frequently occur at the interfaces of care settings. We examined this further because little has been published about MRPs experienced by patients/carers after discharge from the intensive care unit (ICU).

Methods and Materials

Medication history data were collected before, during, and after ICU admission and by face-to-face semistructured interviews with 21 patients and 13 carers attending the ICU Follow-up Clinic (FC) of our 35-bed adult ICU.

Results

A total of 122 drugs were prescribed regularly before ICU admission, 168 on ICU discharge, 132 at hospital discharge, and 128 at the FC. Medication-related problems were identified with hypnotics/anxiolytics, antidepressants, proton pump inhibitors, and analgesics. Good follow-up was observed in all 4 cases where the antidysrhythmic agent amiodarone was initiated on ICU. Patients/carers described 20 cases of difficulty in obtaining appropriate and timely supplies and 19 of insufficient information.

Conclusions

These results show that our incidence of MRPs after ICU discharge was encouragingly infrequent, in which we attribute it to targeted medicine reconciliation and the availability of our FC. However, MRPs were perceived to stem from inadequate communication at the interfaces of care and the lack of opportunity for patients/carers to obtain relevant information. We recommend that FC should focus on MRPs during their consultation and that further research in this area should be performed to examine our observations further.     

The importance of differentiating between elective and emergency postoperative critical care patients

Purpose

The purpose of the study is to demonstrate the importance of separately analyzing data on elective and emergency surgery patients admitted postoperatively to intensive and intermediate care units.

Materials and Methods

A prospective observational study was performed in a tertiary care university hospital to assess the demographic and clinical differences between emergency and elective surgical patients (>14 years old). Group 1 included patients transferred to a floor bed or the ambulatory surgery unit for discharge home after a short stay (<12 hours) in the postanesthesia care unit. Group 2 patients were admitted to the cardiothoracic intensive care unit (ICU), neurosurgical ICU, general ICU, or for an extended intermediate care postanesthesia care unit stay (>12 hours).

Results

In groups 1 (n = 1059), there were significant differences between the elective and emergency patients. Emergency, as compared with elective group 2 (n= 1883) patients, experienced more severe preexisting illnesses (ie, had higher American Society of Anesthesiology classifications), underwent different and shorter operations, required prolonged postoperative mechanical ventilation, required longer ICU stays, and had higher mortality.

Conclusions

Substantial differences between elective and emergency surgery patients have important implications when conducting and reporting research on the nature, extent, and outcome of postoperative ICU care.     

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.     

Skin lesions after intensive care procedures: Results of a prospective study

Purpose

To define the skin lesions produced by procedures used in the intensive care unit (ICU) and to examine patients 12 months after discharge from the ICU.

Material and Methods

This was a prospective clinical study in the 14-bed multidisciplinary ICU of a university hospital. Iatrogenic skin lesions (ISL) were examined in 316 patients after ICU discharge.

Results

A total of 189 patients were interviewed 12 months after ICU discharge. More than 85% of the patients had ISL after being discharged from the ICU. The patients with the highest Acute Physiology and Chronic Health Evaluation II score and longest average stay presented the highest number of ISLs. A total of 93 patients (49%) reported some skin lesions after 12 months. All patients who had undergone surgical tracheostomy reported the presence of a scar, but 4 of 24 patients who had undergone percutaneous tracheostomy reported no tracheostomy scar. Only 22% of all patients reported scars caused by vascular catheter access. About half (54.5%) of the patients reported secondary lesions caused by chest draining, and these were predominantly caused by the large-bore tube drainage. All patients reported the presence of a laparatomy scar.

Conclusions

Most patients had identified skin lesions resulting from ICU procedures. Half of all patients were aware of their lesions and reported them at 12 months. Future research is needed to understand whether these lesions cause problems to survivor's quality of life and whether the lesions lead to increased health care utilization.     

Location of patients before transfer to a tertiary care intensive care unit: Impact on outcome

Objective

To evaluate the impact of the source of patients transferred to a tertiary care intensive care unit (ICU) (referring hospital ICU vs referring hospital emergency department [ED]) on outcomes of transferred patients.

Design and Setting

We performed a retrospective review of data contained in the Project Impact database of a medical-surgical ICU at a university hospital.

Patients and Participants

A total of 503 patients transferred from local community hospitals, 283 from EDs and 220 from ICUs, were identified and included. In addition to comparing all ED transfers with all ICU transfers, comparisons between the 2 populations were made for the subgroups of patients with intracranial hemorrhage (group 1), nonhemorrhagic stroke (group 2), and all other patients (group 3).

Measurements and Results

Patients were evaluated for a variety of outcome parameters, including mortality and ICU and hospital length of stay (LOS) according to their location at the referring hospital at the time of transfer: ICU (ICUtx) or ED (EDtx). Mortality was significantly lower among EDtx in all transferred patients as well as in groups 2 and 3 with no difference in mortality identified in group 1. Intensive care unit LOS was shorter for EDtx and the 3 groups, and hospital LOS was shorter among all EDtx and those in group 3. Group 3 EDtx also had lower than predicted mortality.

Conclusions

Transfer of patients to a tertiary care ICU from the ED of a referring hospital is associated with significantly better outcomes than transfers from referring hospital ICUs.     

In-hospital fellow coverage reduces communication errors in the surgical intensive care unit

Background

Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events.

Methods

A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods.

Results

Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (P < .0001). Residents communicated 89% of events during IHFC vs 51% of events during HC (P < .001). Communication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, P < .001). Junior residents communicated 66% of events (94% IHFC vs 52% HC, P < .001). Communication errors were lower in all ICUs during IHFC (P < .001).

Conclusions

IHFC reduced communication errors.     

Family experience with intensive care unit care: Association of self-reported family conferences and family satisfaction

Purpose

A family conference is recommended as a best practice to improve communication in the intensive care unit (ICU), but this can be challenging given the setting. This study examined whether family members who reported that a family conference occurred had higher satisfaction than those who did not report that a conference was held.

Materials and Methods

The study used a retrospective data analysis of family satisfaction based on family member's responses to a questionnaire. Families of all the patients admitted to ICUs of 2 quaternary hospitals in an integrated health system were surveyed.

Results

The families of 457 patients who matched the inclusion and exclusion criteria were surveyed with a 55.6% response rate. Family satisfaction with decision making was significantly higher (83.6 vs 78.2, P = .0211) for families who reported that family conferences occurred. No significant difference in the satisfaction with care and overall satisfaction scores was found (84.2 vs 80.0, P = .10). Patients whose families reported a family conference were older and had higher mortality.

Conclusion

This study confirms that families who report attending family conferences are more satisfied with decision making in the ICU. This study highlights the need to increase communication in ICUs.     

Prognostic factors and outcomes of patients with pulmonary hypertension admitted to the intensive care unit

Purpose

Patients with pulmonary hypertension (PH) can decompensate to the point where they require care in the intensive care unit (ICU). Our objective is to examine the outcomes and characteristics of patients with PH admitted to the ICU.

Methods

This is a retrospective study of 99 patients with PH who were admitted to the medical ICU of a single tertiary care center. Baseline characteristics, interventions during ICU admission, and ICU and 6-month outcome were documented. Univariate and multivariate logistic regressions were used to evaluate association of patient characteristics with mortality.

Results

Intensive care unit mortality was 30%, and 6-month mortality was 40%. Acute Physiology and Chronic Health Evaluation II score, World Health Organization Group 3 PH, and preexisting treatment with a prostacyclin at time of ICU admission were associated with worse outcome. Patients who received cardiopulmonary resuscitation had 100% mortality. The requirement for mechanical ventilation and dialysis was also associated with increased mortality. Pulmonary artery catheter placement was associated with reduced mortality, specifically if it was placed early during ICU admission and if associated with a change in the present management.

Conclusions

Mortality is high in critically ill patients with PH. The identification of prognostic baseline characteristics and interventions in the ICU is important and warrants further investigation.     

Preadmission quality of life can predict mortality in intensive care unit—A prospective cohort study

Purpose

We sought to investigate whether preadmission quality of life could act as a predictor of mortality among patients admitted to the intensive care unit (ICU).

Materials and methods

This is a prospective observational study of all patients above the age of 18 years admitted to the ICU with a length of stay longer than 24 hours. Short form 36 (SF-36) and Acute Physiology and Chronic Health Evaluation II (APACHE II) were used. Mortality was assessed during ICU admission, 30, and 90 days hereafter.

Results

We included 318 patients. No patients were lost to follow-up. Using the physical component summary of short form 12 (SF-12) as a predictor of ICU mortality, the area under the curve (0.70; confidence interval, 0.62-0.77) was comparable with that of APACHE II (0.74; confidence interval, 0.67-0.82). The difference between SF-12 and SF-36 was nonsignificant.

Conclusions

Preadmission quality of life, assessed by SF-36 and SF-12, is as good at predicting ICU, 30-, and 90-day mortality as APACHE II in patients admitted to the ICU for longer than 24 hours. This indicates that estimated preadmission quality of life, potentially available in the pre-ICU setting, could aid decision making regarding ICU admission and deserves more attention by those caring for critically ill patients.     

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.