Implementation lessons learnt when evaluating palliative care interventions in the intensive care unit: relationships between implementation determinants, strategies, and models of delivery

BackgroundPalliative and end-of-life care have important roles in intensive care units (ICUs) given symptom burden and rate of mortality in ICUs. However, we do not know how ICU-based palliative care interventions should be implemented. This systematic review aims to identify and synthesise knowledge on how ICU-based palliative care interventions have been implemented and provide critical recommendations for successful implementation.MethodsSystematic review methods following PRISMA reporting guidelines. Search strategy combined palliative care, intensive care, and implementation terms. Searches up to December 2022 of MEDLINE, Embase, Cochrane, CINAHL, and PsycINFO. Components from an adapted Smith’s Implementation Research Logic Model were used to develop themes for reporting intervention characteristics, implementation determinants (barriers and facilitators), implementation strategies, mechanisms, and outcomes, and to synthesise relationships between these components.Results79 included studies: 8 process evaluations, and 71 effectiveness studies. Published evidence on ICU-based palliative care interventions is wide-reaching, but reporting on implementation factors (determinants, strategies, mechanisms) is variable and often lacking. In particular, patient and family-related determinants, and any mechanisms, were not reported. Main facilitators are adequate resources and a symbiotic relationship between palliative care and ICU teams. Main barriers are ICU team reluctance toward palliative care involvement, lack of skills and familiarity, and high ICU acuity. Main implementation strategies were utilising champions, providing education and resources, involving stakeholders, creating adaptable interventions, and building relationships between palliative care and ICU teams. Mechanisms most commonly worked by facilitating collaborative working.ConclusionMost research into ICU-based palliative care interventions does not report on how the intervention is implemented into practice. Patient and family perspectives on implementation are rarely sought. Even with strong effectiveness evidence for an intervention, improvements in care will not be achieved without consideration of context-specific implementation strategies. We provide actionable recommendations to address this and identify the relevant research gaps

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

OBJECTIVE: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. METHODS: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. RESULTS: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. CONCLUSIONS: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care

Telemedicine Enhances Communication in the Intensive Care Unit

Patients admitted to the Intensive Care Unit (ICU) are critically ill and often at extremely high risk of death. These patients receive aggressive interventions to prolong their lives. Despite these measures, many patients still succumb to their illness. Although ICU physicians are good at predicting which patients have a high risk of mortality, they are still offering interventions that do not prolong life, but potentially cause more suffering at the end of life. This is because there is a lack of high quality and early communication to discuss prognosis and establish patients\u27 goals of care. This gap in communication is even more profound when patients are transferring from rural hospitals to busy tertiary care centers. This dissertation discusses the utilization of tele-video conferencing to enhance early communication with family members/loved ones of critically ill patients prior to their transfer from a rural hospital to a tertiary care center. It begins with a description of telemedicine and its uses in the ICU to date. Chapter 2 discusses the poor prognoses of patients receiving high intensity interventions such as cardiopulmonary resuscitation (CPR). The extremely dismal outcomes underscore the importance of early, thorough discussions regarding prognosis and goals of care in these patients. The next chapter describes a pilot study utilizing telemedicine to conduct formal unstructured telemedicine conferences with family members prior to transfer. This study demonstrated that palliative care consultations can be provided via telemedicine for critically ill patients and that adequate preparation and technical expertise are essential. Although this study is limited by the nature of the retrospective review, it is evident that more research is needed to further assess its applicability, utility and acceptability. Chapter 4 describes an investigation into the barriers and facilitators of conducting conferences via telemedicine and the perceptions of clinicians regarding the use of telemedicine for this purpose. This chapter identified unique barriers and facilitators to the use of telemedicine that will need to be addressed when designing a telemedicine intervention for conducting family conferences. This thesis describes the importance and process of implementation of telemedicine for the novel purpose of enhancing early communication among physicians and family members of critically ill loved ones. Further studies are needed to refine and investigate patient and family centered clinical outcomes utilizing this intervention

Protocolised non-invasive compared with invasive weaning from mechanical ventilation for adults in intensive care : the Breathe RCT

Background: Invasive mechanical ventilation (IMV) is a life-saving intervention. Following resolution of the condition that necessitated IMV, a spontaneous breathing trial (SBT) is used to determine patient readiness for IMV discontinuation. In patients who fail one or more SBTs, there is uncertainty as to the optimum management strategy. Objective: To evaluate the clinical effectiveness and cost-effectiveness of using non-invasive ventilation (NIV) as an intermediate step in the protocolised weaning of patients from IMV. Design: Pragmatic, open-label, parallel-group randomised controlled trial, with cost-effectiveness analysis. Setting: A total of 51 critical care units across the UK. Participants: Adult intensive care patients who had received IMV for at least 48 hours, who were categorised as ready to wean from ventilation, and who failed a SBT. Interventions: Control group (invasive weaning): patients continued to receive IMV with daily SBTs. A weaning protocol was used to wean pressure support based on the patient’s condition. Intervention group (non-invasive weaning): patients were extubated to NIV. A weaning protocol was used to wean inspiratory positive airway pressure, based on the patient’s condition. Main outcome measures: The primary outcome measure was time to liberation from ventilation. Secondary outcome measures included mortality, duration of IMV, proportion of patients receiving antibiotics for a presumed respiratory infection and health-related quality of life. Results: A total of 364 patients (invasive weaning, n = 182; non-invasive weaning, n = 182) were randomised. Groups were well matched at baseline. There was no difference between the invasive weaning and non-invasive weaning groups in median time to liberation from ventilation {invasive weaning 108 hours [interquartile range (IQR) 57–351 hours] vs. non-invasive weaning 104.3 hours [IQR 34.5–297 hours]; hazard ratio 1.1, 95% confidence interval [CI] 0.89 to 1.39; p = 0.352}. There was also no difference in mortality between groups at any time point. Patients in the non-invasive weaning group had fewer IMV days [invasive weaning 4 days (IQR 2–11 days) vs. non-invasive weaning 1 day (IQR 0–7 days); adjusted mean difference –3.1 days, 95% CI –5.75 to –0.51 days]. In addition, fewer non-invasive weaning patients required antibiotics for a respiratory infection [odds ratio (OR) 0.60, 95% CI 0.41 to 1.00; p = 0.048]. A higher proportion of non-invasive weaning patients required reintubation than those in the invasive weaning group (OR 2.00, 95% CI 1.27 to 3.24). The within-trial economic evaluation showed that NIV was associated with a lower net cost and a higher net effect, and was dominant in health economic terms. The probability that NIV was cost-effective was estimated at 0.58 at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year. Conclusions: A protocolised non-invasive weaning strategy did not reduce time to liberation from ventilation. However, patients who underwent non-invasive weaning had fewer days requiring IMV and required fewer antibiotics for respiratory infections. Future work: In patients who fail a SBT, which factors predict an adverse outcome (reintubation, tracheostomy, death) if extubated and weaned using NIV? Trial registration: Current Controlled Trials ISRCTN15635197. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 48. See the NIHR Journals Library website for further project information

Business Process Redesign in the Perioperative Process: A Case Perspective for Digital Transformation

This case study investigates business process redesign within the perioperative process as a method to achieve digital transformation. Specific perioperative sub-processes are targeted for re-design and digitalization, which yield improvement. Based on a 184-month longitudinal study of a large 1,157 registered-bed academic medical center, the observed effects are viewed through a lens of information technology (IT) impact on core capabilities and core strategy to yield a digital transformation framework that supports patient-centric improvement across perioperative sub-processes. This research identifies existing limitations, potential capabilities, and subsequent contextual understanding to minimize perioperative process complexity, target opportunity for improvement, and ultimately yield improved capabilities. Dynamic technological activities of analysis, evaluation, and synthesis applied to specific perioperative patient-centric data collected within integrated hospital information systems yield the organizational resource for process management and control. Conclusions include theoretical and practical implications as well as study limitations

Caution: Line-of-Sight in ICU Designs

It has been estimated that by the end of 2015, the U.S. will spend approximately $200 billion in new healthcare facilities construction. Infection prevention, patient and family satisfaction, and technologies influence contemporary designs of critical care units. All of these impacts have created larger patient care units, with a majority of single patient rooms. These larger spaces have created challenges for the clinicians to maintain the line-of-sight. The line-of-sight is one tool clinicians often use to maintain patient safety. Since the seminal publication by the Institute of Medicine in 1999, patient safety concerns have escalated after revealing numerous deaths in U.S. hospitals occur due to error. Nurses are in the forefront for patient safety, especially in the hospital setting, and are responsible for 24/7 assessments, monitoring, surveillance, and care. The one safety tool, the line-of-sight, if obstructed could have an impact on patient safety, and often, it is the environment that creates the obstructions. In the design phase, before construction begins in any new critical care unit, the line-of-sight should be considered for optimal surveillance and safety. Coupling the line-of-sight with the field of human factors engineering may be the next major influence to subsequent generations of healthcare construction

Conducting a Needs Assessment to Inform The Development of a Burnout Mitigation Program for Critical Care Nurses

Burnout among nurses is at monumental levels, contributing to high levels of job dissatisfaction and turnover. Some interventions existed in the literature to support burnout reduction programming among nurses; however, the literature failed to identify effective burnout reduction interventions based upon the specific needs of critical care nurses who face unique stressors related to high patient acuity and other environmental considerations. This project aimed to explore critical care nurses\u27 needs and strategies designed to mitigate burnout in the clinical setting. Outcomes from this assessment would inform future interventions for the early identification and prevention of burnout among critical care nurses. The setting for this project was two intensive care units in a large, suburban hospital in the Rocky Mountain region of the United States. The subjects were nurses with at least one year of experience in the critical care setting. This project used a single-center, descriptive design. This project was guided by the advancing research and clinical practice through close collaboration model—an evidence-based, system-wide model used to advance evidence-based practice implementation and sustainability. An evidence-based needs assessment was created and implemented to measure the current level of burnout and the unmet needs of critical care nurses at the project site. The results were analyzed using descriptive statistical procedures. Based on the findings, an organization-specific burnout mitigation plan will be presented to the project site stakeholders

CONDUCTING A NEEDS ASSESSMENT TO INFORM THE DEVELOPMENT OF A BURNOUT MITIGATION PROGRAM FOR CRITICAL CARE NURSES

Burnout among nurses is at monumental levels, contributing to high levels of job dissatisfaction and turnover. Some interventions existed in the literature to support burnout reduction programming among nurses; however, the literature failed to identify effective burnout reduction interventions based upon the specific needs of critical care nurses who face unique stressors related to high patient acuity and other environmental considerations. This project aimed to explore critical care nurses\u27 needs and strategies designed to mitigate burnout in the clinical setting. Outcomes from this assessment would inform future interventions for the early identification and prevention of burnout among critical care nurses. The setting for this project was two intensive care units in a large, suburban hospital in the Rocky Mountain region of the United States. The subjects were nurses with at least one year of experience in the critical care setting. This project used a single-center, descriptive design. This project was guided by the advancing research and clinical practice through close collaboration model—an evidence-based, system-wide model used to advance evidence-based practice implementation and sustainability. An evidence-based needs assessment was created and implemented to measure the current level of burnout and the unmet needs of critical care nurses at the project site. The results were analyzed using descriptive statistical procedures. Based on iv the findings, an organization-specific burnout mitigation plan will be presented to the project site stakeholders