Clinical stakeholders' opinions on the use of selective decontamination of the digestive tract in critically ill patients in intensive care units : an international Delphi study

Peer reviewedPublisher PD

Evaluating Utilization of an Early Mobility Protocol in an Adult ICU in the Veterans Administration System

Purpose: To evaluate ICU staff’s adherence to a new progressive mobility protocol as part of a quality improvement project in an adult medical-surgical intensive care unit (ICU). Background: Bedrest can lead to complications for hospitalized patients and current literature supports that mobility within the ICU is safe and feasible for critically ill patients. Current evidence based literature identifies barriers to patient mobilization which can be addressed through implementation of a mobility protocol. Utilization of mobility protocols is one way to improve quality of care and prevent common bedrest complications in the critically ill patient population. Methods: Retrospective medical record reviews were conducted pre (n=65) and post (n=54) implementation of the mobility protocol to provide descriptive data regarding staff adherence to the protocol and improvement in unit mobility practices. Activity orders, activity occurrences and type, as well as nurses’ documentation of the protocol phase in admission and daily re-assessments were evaluated. Results: Documentation of activity orders from providers was less than 70% (35 out of 54) after implementation of the protocol. Eighty-one percent (44 out of 54) of the medical records reviewed had mobility phase assessed and documented by nurses on the admission assessment. Shift re-assessment of the patients’ mobility phase was low at 41% (22 out of 54) after implementation of the mobility protocol. Conclusion: Improvement of utilization of the mobility protocol was seen over a six-month period with expanded mobility activities being documented by nursing staff. Additional refinement of the protocol will require more time and effort from key stakeholders and unit champions to improve staff adherence

Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

A critical literature review exploring the challenges of delivering effective palliative care to older people with dementia in the acute hospital setting

Aim. This paper considers the challenges of delivering effective palliative care to older people with dementia and the possible strategies to overcome barriers to endof-life care in these patients. Background. In UK alone, approximately 100 000 people with dementia die each year and as the number of older people increases, dementia is set to become even more prevalent. Dementia is a progressive terminal illness for which there is currently no cure. Patients dying with dementia have significant health-care needs and in recent years it has been recognised that palliative care should be made available to everyone regardless of diagnosis, as this improves comfort and quality of life. Despite this, patients dying with dementia are often still not given access to palliative care services. Method. A review of English language literature published after 1996 to the present day relating to older people with dementia during the terminal phase of their illness. Results. Twenty-nine articles met inclusion criteria for the review. Most originated from North America and UK and were mostly quantitative in nature. Four key themes were identified: difficulties associated with diagnosing the terminal phase of the illness (prognostication); issues relating to communication; medical interventions; and the appropriateness of palliative care intervention. Conclusions.This review reinforces the importance of providing appropriate palliative care to individuals suffering from end-stage dementia and identifies some of the barriers to extending such specialist palliative care provision. Relevance to practice. There is an urgent need to improve palliative care provision for older people with end-stage dementia and, in addition, more research is required on the needs of patients entering the terminal phase of dementia to assist the allocation of appropriate resources and training to ensure quality and equality in the provision of end-of-life care

Assessment of Self-Perceived End-of-Life Care Competencies of Intensive Care Unit Providers

Abstract Background: The need for improved (end-of-life) EOL care in the intensive care unit (ICU) has gained attention in the medical literature over the last 10 years. The purpose of this study is to describe ICU health care providers' self-perceived knowledge, attitudes, and behaviors related to the provision of EOL care as a first step in planning educational interventions for ICU staff. Methods and results: One hundred eighty-five ICU staff members of an academic affiliated tertiary medical center in Milwaukee, Wisconsin received the survey, the Scale of End-of-Life Care in the ICU (EOLC-ICU), a new questionnaire developed for this study. The response rate was 50.3%. Conclusion: We found that having previous EOL care education was common among ICU staff. However, several deficiencies in self-perceived EOL competencies were identified among staff, particularly in the areas of communication, continuity of care, and decision-making process. Nursing and medical staff also had different perceptions on how certain EOL behaviors were carried out in the ICU. Educational interventions will be implemented in our ICU in an effort to improve staff preparedness for the provision of quality EOL care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98456/1/jpm%2E2011%2E0265.pd

The Development and Testing of a Measurement System to Assess Intensive Care Unit Team Performance

Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). Complex procedures are conducted with a diverse team of clinicians with unique roles and responsibilities. Information about care plans and goals must also be developed, communicated, and coordinated across multiple disciplines and transferred effectively between shifts and personnel. The intricacies of routine care are compounded during emergency events, which require ICU teams to adapt to rapidly changing patient conditions while facing intense time pressure and conditional stress. Realities such as these emphasize the need for teamwork skills in the ICU. The measurement of teamwork serves a number of different purposes, including routine assessment, directing feedback, and evaluating the impact of improvement initiatives. Yet no behavioral marker system exists in critical care for quantifying teamwork across multiple task types. This study contributes to the state of science and practice in critical care by taking a (1) theory-driven, (2) context-driven, and (3) psychometrically-driven approach to the development of a teamwork measure. The development of the marker system for the current study considered the state of science and practice surrounding teamwork in critical care, the application of behavioral marker systems across the healthcare community, and interviews with front line clinicians. The ICU behavioral marker system covers four core teamwork dimensions especially relevant to critical care teams: Communication, Leadership, Backup and Supportive Behavior, and Team Decision Making, with each dimension subsuming other relevant subdimensions. This study provided an initial assessment of the reliability and validity of the marker system by focusing on a subset of teamwork competencies relevant to subset of team tasks. Two raters scored the performance of 50 teams along six subdimensions during rounds (n=25) and handoffs (n=25). In addition to calculating traditional forms of reliability evidence [intraclass correlations (ICCs) and percent agreement], this study modeled the systematic variance in ratings associated with raters, instances of teamwork, subdimensions, and tasks by applying generalizability (G) theory. G theory was also employed to provide evidence that the marker system adequately distinguishes teamwork competencies targeted for measurement. The marker system differentiated teamwork subdimensions when the data for rounds and handoffs were combined and when the data were examined separately by task (G coefficient greater than 0.80). Additionally, variance associated with instances of teamwork, subdimensions, and their interaction constituted the greatest proportion of variance in scores while variance associated with rater and task effects were minimal. That said, there remained a large percentage of residual error across analyses. Single measures ICCs were fair to good when the data for rounds and handoffs were combined depending on the competency assessed (0.52 to 0.74). The ICCs ranged from fair to good when only examining handoffs (0.47 to 0.69) and fair to excellent when only considering rounds (0.53 to 0.79). Average measures ICCs were always greater than single measures for each analysis, ranging from good to excellent (overall: 0.69 to 0.85, handoffs: 0.64 to 0.81, rounds: 0.70 to 0.89). In general, the percent of overall agreement was substandard, ranging from 0.44 to 0.80 across each task analysis. The percentage of scores within a single point, however, was nearly perfect, ranging from 0.80 to 1.00 for rounds and handoffs, handoffs, and rounds. The confluence of evidence supported the expectation that the marker system differentiates among teamwork subdmensions. Yet different reliability indices suggested varying levels of confidence in rater consistency depending on the teamwork competency that was measured. Because this study applied a psychometric approach, areas for future development and testing to redress these issues were identified. There also is a need to assess the viability of this tool in other research contexts to evaluate its generalizability in places with different norms and organizational policies as well as for different tasks that emphasize different teamwork skills. Further, it is important to increase the number of users able to make assessments through low-cost, easily accessible rater training and guidance materials. Particular emphasis should be given to areas where rater reliability was less than ideal. This would allow future researchers to evaluate team performance, provide developmental feedback, and determine the impact of future teamwork improvement initiatives

Using Natural Language Processing to Evaluate Electronic Health Records of Patients with Ovarian Cancer for Documentation of Goals of Care

Growing evidence supports the benefits of serious illness communication including goals of care (GOC) discussions and documentation in the electronic health record (EHR). Patients who discuss end-of-life (EOL) care with their clinicians are more likely to have positive outcomes including better-reported quality of life, less distress, and a higher likelihood of receiving care consistent with their preferences. Limited research suggests only a small fraction of ovarian cancer patients have such discussions with their clinicians. Using a novel natural language processing (NLP) methodology, this retrospective and descriptive study explores EHRs for patients with ovarian cancer to characterize documentation of GOC. Using concept unique identifiers (CUIs) as the primary data organizer and means for semantic analysis, a rules-based NLP algorithm was built, refined, and validated that uncovered GOC documentation from the EHR with good accuracy and discrimination. GOC documentation was characterized including evaluation for possible disparities. Elements of GOC documentation were identified for 67.3% of the overwhelmingly Non-Hispanic, White patient sample. Eleven distinct disciplines were identified as clinician authors of GOC-positive notes. Missed opportunities were identified to offer the support of palliative care, and to improve the quality of patients’ EOL experience. While the study investigated for possible disparities based on variables of age, race, ethnicity, and insurance class, the only statistically significant finding was that more GOC-positive notes were identified for Non-White patients compared to Whites (p \u3c .003). This may represent discordance between the health care team’s recommendations and the preferences and GOC expressed by non-White patients. Use of NLP shows promise for future study, interventions, and clinical practice to improve care and nudge closer to delivering goal concordant care for patients dealing with ovarian cancer

Intensive care doctors and nurses personal preferences for intensive Care, as compared to the general population: a discrete choice experiment

Background To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient. Methods Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care. Results A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves. Conclusion The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival

Implementation of a Daily Checklist to Improve Patient Safety and Quality of Care in a Pediatric Intensive Care Unit

Background Multiple industries have demonstrated checklists to be of great value in reducing errors of omission and improving communication. In healthcare, checklists have been shown to ensure patients receive evidence-based, safe care. In a fast paced environment of a critical care unit, adverse events are common and can have significant consequences on patient outcome. Safety guardrails are necessary to minimize naturally occurring human error. Safety checklists help support best practices to standardize care and support processes to improve outcome. Objectives To develop and implement a daily safety checklist in a pediatric intensive care unit (PICU) to enhance clinical care and improve patient outcome. Methods After an extensive review of the literature , a multidisciplinary team was created to determine the structure and content for the checklist then placed on an electronic device. The setting of a 30-bed pediatric intensive care unit (PICU) in an urban academic institution was chosen. The PICU nurse practitioner team was identified as the data collection team. Pre and post-implementation surveys regarding perceptions of benefit of the checklist were administered to the data collection team. Results A total of 447 checklists were completed in thirty days. Data was successfully captured, and a reporting system was established. Results of the checklist were communicated with the multidisciplinary team daily. Surveyed practitioners reported an improved perception of the benefits of the checklist including improved team communication, improved outcomes, identification of safety issues, and the importance of the role in safety after implementation. Conclusion The use of a daily safety checklist in a pediatric critical care unit has the potential to enhance clinical care and improve patient outcome. Multidisciplinary communication, enhanced awareness of safety, and improved team perception of value can be improved from collaborative efforts to improve safety in a high paced critical care environment