The impact of a multidisciplinary approach on caring for ventilator-dependent patients

A scoping review of new implementations of interprofessional bedside rounding models to improve teamwork, care, and outcomes in hospitals

Poor communication within healthcare teams occurs commonly, contributing to inefficiency, medical errors, conflict, and other adverse outcomes. Interprofessional bedside rounds (IBR) are a promising model that brings two or more health professions together with patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. The purpose of this systematic scoping review was to investigate the breadth and quality of IBR literature to identify and describe gaps and opportunities for future research. We followed an adapted Arksey and O'Malley Framework and PRISMA scoping review guidelines. PubMed, CINAHL, PsycINFO, and Embase were systematically searched for key IBR words and concepts through June 2020. Seventy-nine articles met inclusion criteria and underwent data abstraction. Study quality was assessed using the Mixed Methods Assessment Tool. Publications in this field have increased since 2014, and the majority of studies reported positive impacts of IBR implementation across an array of team, patient, and care quality/delivery outcomes. Despite the preponderance of positive findings, great heterogeneity, and a reliance on quantitative non-randomized study designs remain in the extant research. A growing number of interventions to improve safety, quality, and care experiences in hospital settings focus on redesigning daily inpatient rounds. Limited information on IBR characteristics and implementation strategies coupled with widespread variation in terminology, study quality, and design create challenges in assessing the effectiveness of models of rounds and optimal implementation strategies. This scoping review highlights the need for additional studies of rounding models, implementation strategies, and outcomes that facilitate comparative research.

How and why might interprofessional patient- and family-centered rounds improve outcomes among healthcare teams and hospitalized patients? A conceptual framework informed by scoping and narrative literature review methods

Poor communication within healthcare contributes to inefficiencies, medical errors, conflict, and other adverse outcomes. A promising model to improve outcomes resulting from poor communication in the inpatient hospital setting is Interprofessional Patient- and Family-Centered rounds (IPFCR). IPFCR brings two or more health professions together with hospitalized patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. A growing body of literature focuses on implementation and outcomes of IPFCR to improve healthcare quality and team and patient outcomes. Most studies report positive changes following IPFCR implementation. However, conceptual frameworks and theoretical models are lacking in the IPFCR literature and represent a major gap that needs to be addressed to move this field forward. The purpose of this two-part review is to propose a conceptual framework of how IPFCR works. The goal is to articulate a framework that can be tested in subsequent research studies. Published IPFCR literature and relevant theories and frameworks were examined and synthesized to explore how IPFCR works, to situate IPFCR in relation to existing models and frameworks, and to postulate core components and underlying causal mechanisms. A preliminary, context-specific, conceptual framework is proposed illustrating interrelationships between four core components of IPFCR (interprofessional approach, intentional patient and family engagement, rounding structure, shared development of a daily care plan), improvements in communication, and better outcomes.

Effect of Sedatives on In-hospital and Long-term Mortality of Critically Ill Patients Requiring Extended Mechanical Ventilation for ≥ 48 Hours

BACKGROUND

The purpose of this study was to assess the correlation between sedatives and mortality in critically ill patients who required mechanical ventilation (MV) for ≥ 48 hours from 2008 to 2016.

METHODS

We conducted a nationwide retrospective cohort study using population-based healthcare reimbursement claims database. Data from adult patients (aged ≥ 18) who underwent MV for ≥ 48 hours between 2008 and 2016 were identified and extracted from the National Health Insurance Service database. The benzodiazepine group consisted of patients who were administered benzodiazepines for sedation during MV. All other patients were assigned to the non-benzodiazepine group.

RESULTS

A total of 158,712 patients requiring MV for ≥ 48 hours were admitted in 55 centers in Korea from 2008 to 2016. The benzodiazepine group had significantly higher in-hospital and one-year mortality compared to the non-benzodiazepine group (37.0% vs. 34.3%, 55.0% vs. 54.4%, respectively). Benzodiazepine use decreased from 2008 to 2016, after adjusting for age, sex, and mean Elixhauser comorbidity index in the Poisson regression analysis (incidence rate ratio, 0.968; 95% confident interval, 0.954-0.983; P < 0.001). Benzodiazepine use, older age, lower case volume (≤ 500 cases/year), chronic kidney disease, and higher Elixhauser comorbidity index were common significant risk factors for in-hospital and one-year mortality.

CONCLUSION

In critically ill patients undergoing MV for ≥ 48 hour, the use of benzodiazepines for sedation, older age, and chronic kidney disease were associated with higher in-hospital mortality and one-year mortality. Further studies are needed to evaluate the impact of benzodiazepines on the mortality in elderly patients with chronic kidney disease requiring MV for ≥ 48 hours.

Psychological Prophylaxis: An Integrated Psychological Services Program in Trauma Care

The primary medical goals of acute care are restoration of physical health and return to physical function. However, in response to traumatic events and injuries, psychological factors are critical to one's overall recovery. Both pre-morbid psychiatric comorbidities and post-injury psychological compromise affect physical and psychological recovery in inpatient trauma populations. The Psychological Services Program (PSP), a model trauma/acute care program, addresses these critical factors in a Level 1 Trauma Center. The program routinely treats over one-quarter of the trauma patients at any given time. The incorporation of the PSP into treatment team care ensures that patients in need of mental health support can be identified and treated during their recovery. This unique model is recommended as a potential injury prevention and recovery intervention strategy for the myriad mental health comorbidities that may function as risk factors for poor post-injury adaptation and also as risk factors for possible future traumatic injury.

Data Omission by Physician Trainees on ICU Rounds

OBJECTIVES

Incomplete patient data, either due to difficulty gathering and synthesizing or inappropriate data filtering, can lead clinicians to misdiagnosis and medical error. How completely ICU interprofessional rounding teams appraise the patient data set that informs clinical decision-making is unknown. This study measures how frequently physician trainees omit data from prerounding notes ("artifacts") and verbal presentations during daily rounds.

DESIGN

Observational study.

SETTING

Tertiary academic medical ICU with an established electronic health record and where physician trainees are the primary presenters during daily rounds.

SUBJECTS

Presenters (medical student or resident physician), interprofessional rounding team.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We quantified the amount and types of patient data omitted from photocopies of physician trainees' artifacts and audio recordings of oral ICU rounds presentations when compared with source electronic health record data. An audit of 157 patient presentations including 6,055 data elements across nine domains revealed 100% of presentations contained omissions. Overall, 22.9% of data were missing from artifacts and 42.4% from presentations. The interprofessional team supplemented only 4.1% of additional available data. Frequency of trainee data omission varied by data type and sociotechnical factors. The strongest predictor of trainee verbal omissions was a preceding failure to include the data on the artifact. Passive data gathering via electronic health record macros resulted in extremely complete artifacts but paradoxically predicted greater likelihood of verbal omission when compared with manual notation. Interns verbally omitted the most data, whereas medical students omitted the least.

CONCLUSIONS

In an academic rounding model reliant on trainees to preview and select data for presentation during ICU rounds, verbal appraisal of patient data was highly incomplete. Additional trainee oversight and education, improved electronic health record tools, and novel academic rounding paradigms are needed to address this potential source of medical error.

Effect of Institutional Case Volume on In-Hospital and Long-Term Mortality in Critically Ill Patients Requiring Mechanical Ventilation for 48 Hours or More

BACKGROUND

The purpose of this study was to evaluate whether institutional case volume affects clinical outcomes in patients receiving mechanical ventilation for 48 hours or more.

METHODS

We conducted a nationwide retrospective cohort study using the database of Korean National Healthcare Insurance Service. Between January 2007 and December 2016, 158,712 adult patients were included at 55 centers in Korea. Centers were categorized according to the average annual number of patients: > 500, 500 to 300, and < 300.

RESULTS

In-hospital mortality rates in the high-, medium-, and low-volume centers were 32.6%, 35.1%, and 39.2%, respectively. After adjustment, in-hospital mortality was significantly higher in low-volume centers (adjusted odds ratio [OR], 1.332; 95% confidence interval [CI], 1.296-1.368; P < 0.001) and medium-volume centers (adjusted OR, 1.125; 95% CI, 1.098-1.153; P < 0.001) compared to high-volume centers. Long-term survival for up to 8 years was better in high-volume centers.

CONCLUSION

Centers with higher case volume (> 500 patients/year) showed lower in-hospital mortality and long-term mortality, compared to centers with lower case volume (< 300 patients/year) in patients who required mechanical ventilation for 48 hours or more.

An Analysis of Pay-for-Performance Schemes and Their Potential Impacts on Health Systems and Outcomes for Patients

Pay-for-performance (P4P) programs have been introduced into the Canadian medical system in the last decades. This paper examines the underlying characteristics of P4P and describes both their advantages and drawbacks. Most P4P programs provide the advantage of rewarding medical acts, thus providing an incentive to take on complex patients. There is a variety of nuanced P4P initiatives, which provide financial incentive according to differing criteria, based on quality measures, incentives, and/or benchmark structures. However, there is no conclusive evidence demonstrating that P4P programs provide better value for money than traditional pay schemes, regardless of particular structural choices. Some evidence has even shown that P4P may be detrimental, especially in disadvantaged and high-risk populations. Additionally, there are a number of ethical and practical concerns that arise with the use of P4P, such as the risk of financial incentives being misused or misinterpreted and patients being refused or referred during treatment. P4P initiatives require careful examination and the creation of solid, evidence-based criteria for evaluation and implementation in Canadian medical systems.

The effect of an improvement of experience and training in extracorporeal membrane oxygenation management on clinical outcomes

BACKGROUND/AIMS

The use of extracorporeal membrane oxygenation (ECMO) is spreading rapidly, with successful procedures reported in the ECMO for Severe Adult Respiratory failure (CESAR) trial and treatment of the H1N1 pandemic. However, ECMO is associated with a high mortality rate. This study aimed to show that increased experience and improved teamwork through education may reduce the mortality rate associated with ECMO.

METHODS

A retrospective study was performed. Data were collected from January 1, 2009, to December 31, 2011. The data were divided into two periods: 2009/2010 (period 1) and 2011 (period 2). The protocol and training program were applied during period 2.

RESULTS

Seventy-six patients were included. The most common disease requiring ECMO support was pneumonia (43.4%). ECMO was applied within 7 days in 76.3% of patients. The primary outcomes, such as Intensive Care Unit (ICU) and hospital mortality rates, were higher during period 1 (91.3%) than period 2 (66.7%, p = 0.013). A multivariate analysis revealed that ECMO weaning failure was the only factor associated with ICU and hospital mortality (ICU mortality: hazard ratio [HR], 11.349; 95% confidence interval [CI], 1.281 to 100.505; p = 0.029; hospital mortality: HR, 17.976; 95% CI, 2.263 to 142.777; p = 0.006).

CONCLUSIONS

The mortality rate associated with the ECMO procedure decreased following the ECMO training program. However, applying the training program to ECMO management is not an independent factor for the mortality rate. Further studies should be performed to help reduce the mortality rate associated with ECMO.

Relationship between multidisciplinary critical care and burn patients survival: A propensity-matched national cohort analysis

OBJECTIVE

The aims of this study are: firstly, to investigate if admission to specialized burn critical care units leads to better clinical outcomes; secondly, to elucidate if the multidisciplinary critical care contributes to this superior outcome.

METHODS

A multi-centre cohort analysis of a prospectively collected national database of 1759 adult burn patients admitted to 13 critical care units in England and Wales between 2005 and 2011. Units were contacted via telephone to establish frequency and constitution of daily ward rounds. Critical care units were categorized into 3 settings: specialized burns critical care units, generalized critical care units and 'visiting' critical care units. Multivariate logistic regression analysis and propensity dose-response analysis were used to calculate risk adjusted mortality.

RESULTS

Multivariate logistic regression analysis shows that admission to a specialized burn critical care service is independently associated with significant survival benefit compared to generalized critical care unit (adjusted OR for in-hospital death 1.81, [95% CI, 1.24, 2.66]) and 'visiting' critical care services (adjusted OR for in-hospital death 2.24 [95% CI, 1.49, 3.38]). Further analysis using propensity dose-response analysis demonstrates that risk-adjusted in-hospital mortality rate decreased as the dose of multidisciplinary care increased, with an adjusted odds ratio of 1 (specialized burn critical care units), 1.81 (generalized critical care units) and 2.24 ('visiting' critical care units).

CONCLUSIONS

Admission to a specialized burn critical care service is independently associated with significant survival benefit. This is, at least in part, due to care being provided by a fully integrated multidisciplinary team.

Accuracy of Laboratory Data Communication on ICU Daily Rounds Using an Electronic Health Record

Supplemental Digital Content is available in the text.

Objectives:

Accurately communicating patient data during daily ICU rounds is critically important since data provide the basis for clinical decision making. Despite its importance, high fidelity data communication during interprofessional ICU rounds is assumed, yet unproven. We created a robust but simple methodology to measure the prevalence of inaccurately communicated (misrepresented) data and to characterize data communication failures by type. We also assessed how commonly the rounding team detected data misrepresentation and whether data communication was impacted by environmental, human, and workflow factors.

Design:

Direct observation of verbalized laboratory data during daily ICU rounds compared with data within the electronic health record and on presenters’ paper prerounding notes.

Setting:

Twenty-six-bed academic medical ICU with a well-established electronic health record.

Subjects:

ICU rounds presenter (medical student or resident physician), interprofessional rounding team.

Interventions:

None.

Measurements and Main Results:

During 301 observed patient presentations including 4,945 audited laboratory results, presenters used a paper prerounding tool for 94.3% of presentations but tools contained only 78% of available electronic health record laboratory data. Ninty-six percent of patient presentations included at least one laboratory misrepresentation (mean, 6.3 per patient) and 38.9% of all audited laboratory data were inaccurately communicated. Most misrepresentation events were omissions. Only 7.8% of all laboratory misrepresentations were detected.

Conclusion:

Despite a structured interprofessional rounding script and a well-established electronic health record, clinician laboratory data retrieval and communication during ICU rounds at our institution was poor, prone to omissions and inaccuracies, yet largely unrecognized by the rounding team. This highlights an important patient safety issue that is likely widely prevalent, yet underrecognized.

A Survey of Rounding Practices in Canadian Adult Intensive Care Units

OBJECTIVE

To describe rounding practices in Canadian adult Intensive Care Units (ICU) and identify opportunities for improvement.

DESIGN

Mixed methods design. Cross sectional survey of Canadian Adult ICUs (n = 180) with purposefully sampled follow-up interviews (n = 7).

MEASUREMENTS AND MAIN RESULTS

Medical directors representing 111 ICUs (62%) participated in the survey. Rounding practices varied across ICUs with the majority reporting the use of interprofessional rounds (81%) that employed an open (94%) and collaborative (86%) approach, occurred at the patient's bedside (82%), and started at a standard time (79%) and standard location (56%). Most participants reported that patients (83%) and family members (67%) were welcome to attend rounds. Approximately half of ICUs (48%) used tools to facilitate rounds. Interruptions during rounds were reported to be common (i.e., ≥ 1 interruption for ≥ 50% of patients) in 46% of ICUs. Four themes were identified from qualitative analysis of participant responses to open-ended survey questions and interviews: multidisciplinarity, patient and family involvement, factors influencing productivity, and teaching and learning.

CONCLUSIONS

There is considerable variation in current rounding practices in Canadian medical/surgical ICUs. Opportunities exist to improve ICU rounds including ensuring the engagement of essential participants, clearly defining participant roles, establishing a standardized approach to the rounding process, minimizing interruptions, modifying the role of teaching, utilizing a structured rounding tool, and developing a metric for measuring rounding quality.

Association Between Vitamin D Status and Weaning From Prolonged Mechanical Ventilation in Survivors of Critical Illness

BACKGROUND

In this study, we examined the association between 25-hydroxyvitamin D (25(OH)D) concentration and successful weaning from mechanical ventilation in a cohort of ICU survivors requiring prolonged mechanical ventilation.

METHODS

This was a retrospective cohort study of ICU survivors admitted to a long-term acute care hospital. Demographic data were extracted from medical records, including 25(OH)D concentrations drawn on admission. Subjects were divided into 2 groups based on their 25(OH)D concentrations (deficient, < 20 ng/mL; not deficient, ≥ 20 ng/mL), and associations between 25(OH)D concentration and successful weaning were calculated.

RESULTS

A total of 183 subjects were studied. A high prevalence of 25(OH)D deficiency was found (61%, 111/183). No association was found between 25(OH)D concentration and weaning from mechanical ventilation. Increased comorbidity burden (Charlson comorbidity index) was associated with decreased odds of weaning (odds ratio of 0.50, 95% CI 0.25-0.99, P = .05).

CONCLUSIONS

Vitamin D deficiency is common in ICU survivors requiring prolonged mechanical ventilation. Surprisingly, there was no significant relationship between 25(OH)D concentration and successful weaning. This finding may be due to the low 25(OH)D concentrations seen in our subjects. Given what is known about vitamin D and lung function and given the low vitamin D concentrations seen in patients requiring long-term ventilatory support, interventional studies assessing the effects of 25(OH)D supplementation in these patients are needed.

Facilitators of an interprofessional approach to care in medical and mixed medical/surgical ICUs: a multicenter qualitative study

The purpose of this study was to describe clinicians' perceptions of interprofessional collaboration in the intensive care unit and identify factors associated with interprofessional collaboration. We performed 64 semi-structured interviews in seven hospitals with ICU nurses, physicians, respiratory therapists, nurse managers, clinical pharmacists, and dieticians. ICU clinicians perceived two distinct types of facilitators to interprofessional collaboration in critical care: cultural and structural. In the critical care setting, cultural and structural facilitators worked independently as well as in concert to create effective interprofessional collaboration. Initiatives aimed at creating and facilitating interprofessional collaboration should focus attention on cultural and structural facilitators to improve patient care and team effectiveness.

Facilitators of an interprofessional approach to care in medical and mixed medical/surgical ICUs: a multicenter qualitative study

The purpose of this study was to describe clinicians' perceptions of interprofessional collaboration in the intensive care unit and identify factors associated with interprofessional collaboration. We performed 64 semi-structured interviews in seven hospitals with ICU nurses, physicians, respiratory therapists, nurse managers, clinical pharmacists, and dieticians. ICU clinicians perceived two distinct types of facilitators to interprofessional collaboration in critical care: cultural and structural. In the critical care setting, cultural and structural facilitators worked independently as well as in concert to create effective interprofessional collaboration. Initiatives aimed at creating and facilitating interprofessional collaboration should focus attention on cultural and structural facilitators to improve patient care and team effectiveness.

The association between comorbid illness, colonization status, and acute hospitalization in patients receiving prolonged mechanical ventilation

BACKGROUND

Long-term acute care (LTAC) hospitals provide specialized care for survivors of critical illness who require prolonged mechanical ventilation. These chronically ill patients often have multiple comorbidities and are colonized with antibiotic-resistant organisms. We investigated the association of comorbidities and colonization status with outcomes in patients requiring prolonged mechanical ventilation in an LTAC facility. We hypothesized that comorbidity burden and colonization with multiple drug resistant organisms would be associated with worse clinical outcomes.

METHODS

We performed a retrospective, cohort study of 157 mechanically ventilated subjects in an urban LTAC facility admitted from January 2007 to September 2009. Comorbidity burden was documented from pre-admission data using the Charlson Comorbidity Index. Colonization data were obtained from surveillance cultures. Outcomes studied included transfer back to acute care facilities, stay, and ventilator weaning status.

RESULTS

Within 60 days, 58.6% of subjects were transferred back to an acute care facility. The most common reason for transfer was infection/sepsis (37%). The Charlson Comorbidity Index of subjects transferred to acute care, versus those who were not, was 4.9 ± 3.1 versus 3.6 ± 2.7 (P = .01), an odds ratio of 1.1 for each 1-point increase in Charlson Comorbidity Index (95% CI 1.03-1.71, P = .02). Colonization with acinetobacter was associated with higher incidence of transfer (71% vs 51%, P = .01). The odds ratio for transfer to acute care was 1.3 for each additional organism colonizing a subject (95% CI 1.11-1.53, P = .006).

CONCLUSIONS

Higher comorbidity burden and colonization status were associated with increased risk of transfer to acute care. Further investigation is needed to clarify this relationship between comorbidity burden and colonization with change in clinical status.

Mortality among patients admitted to strained intensive care units

RATIONALE

The aging population may strain intensive care unit (ICU) capacity and adversely affect patient outcomes. Existing fluctuations in demand for ICU care offer an opportunity to explore such relationships.

OBJECTIVES

To determine whether transient increases in ICU strain influence patient mortality, and to identify characteristics of ICUs that are resilient to surges in capacity strain.

METHODS

Retrospective cohort study of 264,401 patients admitted to 155 U.S. ICUs from 2001 to 2008. We used logistic regression to examine relationships of measures of ICU strain (census, average acuity, and proportion of new admissions) near the time of ICU admission with mortality.

MEASUREMENTS AND MAIN RESULTS

A total of 36,465 (14%) patients died in the hospital. ICU census on the day of a patient's admission was associated with increased mortality (odds ratio [OR], 1.02 per standardized unit increase; 95% confidence interval [CI]: 1.00, 1.03). This effect was greater among ICUs employing closed (OR, 1.07; 95% CI: 1.02, 1.12) versus open (OR, 1.01; 95% CI: 0.99, 1.03) physician staffing models (interaction P value = 0.02). The relationship between census and mortality was stronger when the census was composed of higher acuity patients (interaction P value < 0.01). Averaging strain over the first 3 days of patients' ICU stays yielded similar results except that the proportion of new admissions was now also associated with mortality (OR, 1.04 for each 10% increase; 95% CI: 1.02, 1.06).

CONCLUSIONS

Several sources of ICU strain are associated with small but potentially important increases in patient mortality, particularly in ICUs employing closed staffing models. Although closed ICUs may promote favorable outcomes under static conditions, they are susceptible to being overwhelmed by patient influxes.

[Organization of mechanical ventilation in French Intensive care units]

Objectifs

Dans le domaine de la ventilation en réanimation, préciser le matériel, la formation des équipes, la maintenance et les référentiels disponibles.

Type d’étude

Enquête déclarative.

Méthodes

Entre septembre et décembre 2010, ont été recueillis : répartition et type des ventilateurs (ventilateurs lourds, de dépannage, ventilation non invasive (VNI) et de transport), formation des médecins et des soignants, maintenance, présence de référentiels. Les résultats sont présentés en médiane/extrêmes ou proportions.

Résultats

Les 62 unités analysées étaient équipées de 15 ventilateurs (médiane, extrêmes 1−50), de plusieurs marques 47 (76 %) fois. Des ventilateurs étaient spécifiquement disponibles pour la VNI 22 fois (35 %), le dépannage 49 (79 %) fois, et le transport dans 100 % des unités. Les soignants étaient formés par les médecins dans 54 unités (87 %) ou par un industriel dans 29 unités (47 %). Les médecins étaient formés par les médecins séniors dans 55 unités (89 %) ou par un industriel dans 21 unités (34 %). Les formations étaient ponctuelles dans 24 (39 %) unités ou semestrielles 16 (26 %) fois. L’entretien était effectué par le personnel de réanimation dans 39 (63 %) unités, par du personnel dédié (17 [27 %] cas), du personnel biomédical (14 [23 %] cas). Un référentiel pour l’entretien existait dans 48 (77 %) unités, le réglage du ventilateur 22 (35 %) fois et en cas de panne 20 (32 %) fois.

Conclusion

Cette première enquête montre une grande hétérogénéité des pratiques et de distribution du matériel. La formation et la connaissance des équipements sont des cibles pour l’amélioration de la sécurité.

Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82

Over the past two decades, there has been an exponential and enthusiastic adoption of simulation in healthcare education internationally. Medicine has learned much from professions that have established programs in simulation for training, such as aviation, the military and space exploration. Increased demands on training hours, limited patient encounters, and a focus on patient safety have led to a new paradigm of education in healthcare that increasingly involves technology and innovative ways to provide a standardized curriculum. A robust body of literature is growing, seeking to answer the question of how best to use simulation in healthcare education. Building on the groundwork of the Best Evidence in Medical Education (BEME) Guide on the features of simulators that lead to effective learning, this current Guide provides practical guidance to aid educators in effectively using simulation for training. It is a selective review to describe best practices and illustrative case studies. This Guide is the second part of a two-part AMEE Guide on simulation in healthcare education. The first Guide focuses on building a simulation program, and discusses more operational topics such as types of simulators, simulation center structure and set-up, fidelity management, and scenario engineering, as well as faculty preparation. This Guide will focus on the educational principles that lead to effective learning, and include topics such as feedback and debriefing, deliberate practice, and curriculum integration - all central to simulation efficacy. The important subjects of mastery learning, range of difficulty, capturing clinical variation, and individualized learning are also examined. Finally, we discuss approaches to team training and suggest future directions. Each section follows a framework of background and definition, its importance to effective use of simulation, practical points with examples, and challenges generally encountered. Simulation-based healthcare education has great potential for use throughout the healthcare education continuum, from undergraduate to continuing education. It can also be used to train a variety of healthcare providers in different disciplines from novices to experts. This Guide aims to equip healthcare educators with the tools to use this learning modality to its full capability.

A systematic review of evidence-informed practices for patient care rounds in the ICU*

OBJECTIVES

Patient care rounds are a key mechanism by which healthcare providers communicate and make patient care decisions in the ICU but no synthesis of best practices for rounds currently exists. Therefore, we systematically reviewed the evidence for facilitators and barriers to patient care rounds in the ICU.

DATA SOURCES

Search of Medline, Embase, CINAHL, PubMed, and the Cochrane library through September 21, 2012.

STUDY SELECTION

Original, peer-reviewed research studies (no methodological restrictions) were selected, which described current practices, facilitators, or barriers to healthcare provider rounding in the ICU.

DATA EXTRACTION

Two authors with methodological and content expertise independently abstracted data using a prespecified abstraction tool.

DATA SYNTHESIS

The literature search identified 7,373 citations. Reviews of abstracts led to the retrieval of 136 full text articles for assessment; 43 articles in three languages (English, German, Spanish) were selected for review. Of these, 13 were ethnographic studies and 15 uncontrolled before-after studies. Six studies used control groups, including one cross-over randomized, one time-series, three cohort, and one controlled before-after study. A total of 13 facilitators and 9 barriers to patient care rounds were identified through a narrative and meta-synthesis of included studies. Identified facilitators suggest that the quality of rounds is improved when conducted by a multidisciplinary group of providers, with explicitly defined roles, using a standardized structure and goal-oriented approach that includes a best practices checklist. Barriers to quality patient care rounds include poor information retrieval and documentation, interruptions, long rounding times, and allied healthcare provider perceptions of not being valued by rounding physicians.

CONCLUSIONS

Although the evidence base for best practices of patient care rounds in the ICU is limited, several practical and low-risk practices can be considered for implementation.

ICU capacity strain and the quality and allocation of critical care

PURPOSE OF REVIEW

Increasing demand for critical care, with limited potential for comparable expansion of supply, may strain the abilities of ICUs to provide high-quality care in an equitable fashion. Efforts to counter the untoward consequences for the quality and ethics of critical care delivery are limited by the absence of a specific and validated metric of ICU capacity strain.

RECENT FINDINGS

This manuscript presents a conceptual framework for ICU capacity strain, considers what data elements may contribute to it, and suggests methods for determining the optimal metric. Next, it outlines the range of potential consequences of increased capacity strain, in terms of both the quality and ethics of care delivered. Finally, consideration is given to how untoward consequences of ICU capacity strain might be mitigated through better understanding of what makes some ICUs better able than others to withstand temporal fluctuations in the demand for their services.

SUMMARY

Development of an appropriately accurate and parsimonious measure of ICU capacity strain may augment the precision of future critical care outcomes research by reducing unexplained variance attributable to temporal fluctuations in ICU-level factors; elucidate organizational characteristics that make some ICUs better able to withstand high-capacity strain without substantive degradations in quality; and enhance the transparency of critical care rationing while helping to improve its equity and efficiency, thereby promoting the ethics of this inevitable practice.

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice

AIM

To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice.

METHODS

Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion.

RESULTS

Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies.

CONCLUSION

Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.

The role of an interdisciplinary transplant team on living donation kidney transplantation program

During the last decades, the disparity between the organ supply and the demand for kidney transplantation in Europe has led to consider living donors as a more acceptable option. In the last 7 years, we have established an interdisciplinary supporting transplant team to increase the rate of living donation. After 2001, the new interdisciplinary transplant team consisted of a transplant surgeon, a nephrologist, a pediatrician, a radiologist, a psychologist, a transplant coordinator, and a transplant nurse. We performed a prospective analysis to examine the effect of implementing this team on our living donation program. Demographic data, the annual number of procedures, the duration of waiting, and the cold ischemia time were evaluated among brain-dead and living donors. From January 2002 until December 2008, the number of patients who were annually on the waiting list increased 42% (from 377 to 536 patients). Consequently, the number of the total kidney transplants increased from 81 to 120 with an annual median of 98 cases. By implementing the interdisciplinary transplant team, a significant increase of living kidney donors was observed: from 18 to 42 cases; median = 27). In the last 7 years, a total number of 796 kidney transplants have been performed: 567 from brain-dead and 229 from living donors. In 2001, the waiting list times for recipients who received grafts from brain-dead versus living donors were 1356 versus 615 days respectively. Compared with 2008, the duration on the waiting list decreased significantly for patients receiving a living donor graft, whereas there was a slight increase for the patients in the brain-dead group: brain death versus living donors: 1407 versus 305 days. The interdisciplinary approach has also reduced the cold ischemia time for the living donor recipients: 3 hours and 42 minutes in 2001 versus 2 hours and 50 minutes in 2008. During the last years, by implementing an interdisciplinary transplant team, supporting living donor procedures has produce a gradual increase in the number of kidney transplants from living donors with a remarkable decrease in waiting and cold ischemia times, the latter presumably influencing graft quality.

An official American Thoracic Society policy statement: pay-for-performance in pulmonary, critical care, and sleep medicine

RATIONALE

Pay-for-performance is a model for health care financing that seeks to link reimbursement to quality. The American Thoracic Society and its members have a significant stake in the development of pay-for-performance programs.

OBJECTIVES

To develop an official ATS policy statement addressing the role of pay-for-performance in pulmonary, critical care and sleep medicine.

METHODS

The statement was developed by the ATS Health Policy Committee using an iterative consensus process including an expert workshop and review by ATS committees and assemblies.

MEASUREMENTS AND MAIN RESULTS

Pay-for-performance is increasingly utilized by health care purchasers including the United States government. Published studies generally show that programs result in small but measurable gains in quality, although the data are heterogeneous. Pay-for-performance may result in several negative consequences, including the potential to increase costs, worsen health outcomes, and widen health disparities, among others. Future research should be directed at developing reliable and valid performance measures, increasing the efficacy of pay-for-performance programs, minimizing negative unintended consequences, and examining issues of costs and cost-effectiveness. The ATS and its members can play a key role in the design and evaluation of these programs by advancing the science of performance measurement, regularly developing quality metrics alongside clinical practice guidelines, and working with payors to make performance improvement a routine part of clinical practice.

CONCLUSIONS

Pay-for-performance programs will expand in the coming years. Pulmonary, critical care and sleep practitioners can use these programs as an opportunity to partner with purchasers to improve health care quality.

The effect of multidisciplinary care teams on intensive care unit mortality

BACKGROUND

Critically ill patients are medically complex and may benefit from a multidisciplinary approach to care.

METHODS

We conducted a population-based retrospective cohort study of medical patients admitted to Pennsylvania acute care hospitals (N = 169) from July 1, 2004, to June 30, 2006, linking a statewide hospital organizational survey to hospital discharge data. Multivariate logistic regression was used to determine the independent relationship between daily multidisciplinary rounds and 30-day mortality.

RESULTS

A total of 112 hospitals and 107 324 patients were included in the final analysis. Overall 30-day mortality was 18.3%. After adjusting for patient and hospital characteristics, multidisciplinary care was associated with significant reductions in the odds of death (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.76-0.93 [P = .001]). When stratifying by intensivist physician staffing, the lowest odds of death were in intensive care units (ICUs) with high-intensity physician staffing and multidisciplinary care teams (OR, 0.78; 95% CI, 0.68-0.89 [P < .001]), followed by ICUs with low-intensity physician staffing and multidisciplinary care teams (OR, 0.88; 95% CI, 0.79-0.97 [P = .01]), compared with hospitals with low-intensity physician staffing but without multidisciplinary care teams. The effects of multidisciplinary care were consistent across key subgroups including patients with sepsis, patients requiring invasive mechanical ventilation, and patients in the highest quartile of severity of illness.

CONCLUSIONS

Daily rounds by a multidisciplinary team are associated with lower mortality among medical ICU patients. The survival benefit of intensivist physician staffing is in part explained by the presence of multidisciplinary teams in high-intensity physician-staffed ICUs.

A new approach to postpartum rounds: patient-centered collaborative care improves efficiency

OBJECTIVE

At our institution, traditional postpartum rounds were time consuming and inefficient with a low percentage (approximately 12%) of patients meeting the goal of being discharged by 11:00 am. A patient-centered collaborative care (PCCC) initiative was implemented to improve discharge efficiency, staff communication, and patient satisfaction. We investigated whether this paradigm shift to PCCC could improve clinical inefficiencies and timely discharge.

METHODS

The PCCC rounding system was created by a representative group of physicians, residents, nurses, case managers, and social workers. An intervention study was conducted to examine the impact of PCCC during which physicians, residents, medical students, nurses, case managers, and social workers made rounds together. Efficiency data were collected for patients whose infants were delivered by the obstetric service for a 1-month period before and 6 months after implementing PCCC. Comparisons were made on the time of discharge and whether Foley catheter removal affected discharge time. χ(2) test, Wilcoxon 2-sample test, and Pearson correlation coefficient were used where appropriate.

RESULTS

Three hundred five patients were included in this analysis, of which 156 participated in traditional postpartum rounds and 149 in PCCC rounds. Discharge efficiency significantly improved with PCCC rounds, with 20.8% of patients being discharged by 11:00 am as compared to 11.5% for traditional postpartum rounds (P  =  .03). Early Foley catheter removal was significantly associated with time to discharge order (Pearson correlation coefficient, 0.22; P  =  .01) and discharge time (Pearson correlation coefficient, 0.28; P  =  .002).

CONCLUSIONS

Patient-centered collaborative care rounds improve the efficiency of postpartum care and discharge time.

Daily multidisciplinary discharge rounds in a trauma center: a little time, well spent

BACKGROUND

Patient flow in a trauma center can be improved by multidisciplinary discharge rounds (MDR), but the content and logistics of MDR discussions have not been well quantified for purposes of improvement and adoption. We characterized the discussion content and time spent during MDRs and measured success rates in implementing communicated plans.

METHODS

Bedside MDRs in seven patient care units were observed during consecutive working days in a major academic trauma center.

PATIENT

Discussions were timed and their content coded. Coding reliability was assessed with kappa statistics. Implementations of communicated plans were assessed during sequential working days.

RESULTS

MDRs over 23 days comprising 1,769 patient-discussions were observed. MDRs lasted a median of 34 minutes for a median of 78 patients. Kappa statistics for the discussions were 0.63 to 0.96. Each patient-discussion lasted a median of 13 seconds (range, 2 seconds-233 seconds), and 96% lasted less than a minute. Clinical topics were presented in 71.5%, new complications in 12%, discharge plans in 67%, surgical plans in 19%, and care advancement in 8% of them. Discussions >30 seconds duration were likely to contain exploration of care advancement, systems related, and clinical topics (p < 0.05). Advancement of care exploration correlated moderately with census of the trauma center (r = 0.53, p = 0.01). Ninety-four percent of the communicated plans were implemented with most delays caused by systems factors (82%).

CONCLUSIONS

The short duration and goal-focused communication may have made MDRs sustainable. Given the benefits of successful implementation of communicated plans and previously demonstrated improved patient outcomes, time for MDRs is well spent.

Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review

OBJECTIVES

The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes.

METHODS

A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria.

RESULTS

A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation.

CONCLUSIONS

Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.

Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment

BACKGROUND

We studied the reasons why patients undergoing thoracenteses performed in our outpatient pulmonary clinic had a higher frequency of iatrogenic pneumothorax compared to that in the concurrent radiology practice in our institution, which utilizes ultrasound guidance. We reviewed our practice model and implemented a unique experiential training paradigm in a zero-risk simulation environment to improve efficacy, timeliness, service orientation, and safety.

METHODS

We retrospectively determined the rate of clinically significant pneumothoraces in our practice (phase I, July 1, 2001, to June 30, 2002). The training system redesign included the following: (1) a designated group of pulmonologist instructors dedicated to treating pleural disease and reducing the number of iatrogenic complications; (2) the use of ultrasound image guidance for all thoracenteses; and (3) structured proficiency and competency standards for proceduralists. Postintervention (phase II) data were prospectively collected (January 2005 to December 2006) and compared with our baseline data.

RESULTS

The baseline rate of pneumothorax was 8.6% (5 of 58 patients) in our pulmonary practice. Following intervention (phase II), the rate of pneumothorax declined to 1.1% (p = 0.0034). During phase II, the number of thoracenteses performed increased (186 vs 58 per year, respectively; p < 0.05). The iatrogenic pneumothorax rate was stable in the 2 years following intervention (2005, 0.7% [1 of 137 pneumothoraces]; 2006, 1.3% [3 of 226 pneumothoraces]; p > 0.9). Postintervention complications included procedure-related pain (n = 19), cough (n = 4), and hypotension (n = 10).

CONCLUSIONS

An improvement program that included simulation, ultrasound guidance, competency testing, and performance feedback reduced iatrogenic risk to patients. We recommend application of this process to procedural practices.

Teamwork in obstetric critical care

Whether seeing a patient in the ambulatory clinic environment, performing a delivery or managing a critically ill patient, obstetric care is a team activity. Failures in teamwork and communication are among the leading causes of adverse obstetric events, accounting for over 70% of sentinel events according to the Joint Commission. Effective, efficient and safe care requires good teamwork. Although nurses, doctors and healthcare staff who work in critical care environments are extremely well trained and competent medically, they have not traditionally been trained in how to work well as part of a team. Given the complexity and acuity of critical care medicine, which often relies on more than one medical team, teamwork skills are essential. This chapter discusses the history and importance of teamwork in high-reliability fields, reviews key concepts and skills in teamwork, and discusses approaches to training and working in teams.

Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study

PURPOSE

In pediatric teaching hospitals, medical decisions are traditionally made by the attending and resident physicians during rounds that do not include parents. This structure limits the ability of the medical team to provide "family-centered care" and the attending physician to model communication skills. The authors thus set out to identify how parents responded to participation in interdisciplinary teaching rounds conducted in a large tertiary care children's teaching hospital.

METHOD

A qualitative descriptive study was conducted using data from semistructured interviews of parents who had participated in rounds on the inpatient medical unit of a large academic children's hospital. From December 2004 to April 2005, 18 parents were interviewed after their participation in rounds. Questions assessed their experiences, expectations, preferred communication styles, and suggestions for improvement. Transcripts of the interviews were analyzed using qualitative content analysis.

RESULTS

Being able to communicate, understand the plan, and participate with the team in decision making about their child's care were the most frequently cited outcomes of importance to parents. All 18 participants described the overall experience as positive, and 17 of 18 described themselves as "comfortable" with inclusion in rounds. Use of lay terminology and inclusion of nurses in rounds were preferred.

CONCLUSIONS

Including parents on ward rounds at a teaching hospital was viewed positively by parents. Specific themes of particular importance to parents were identified. Further study is needed to assess the impact of inclusion of parents on rounds on patient outcomes and the resident experience.

Intensivist physician staffing and the process of care in academic medical centres

BACKGROUND

Although intensivist physician staffing is associated with improved outcomes in critical care, little is known about the mechanism leading to this observation.

OBJECTIVE

To determine the relationship between intensivist staffing and select process-based quality indicators in the intensive care unit.

RESEARCH DESIGN

Retrospective cohort study in 29 academic hospitals participating in the University HealthSystem Consortium Mechanically Ventilated Patient Bundle Benchmarking Project.

PATIENTS

861 adult patients receiving prolonged mechanical ventilation in an intensive care unit.

RESULTS

Patient-level information on physician staffing and process-of-care quality indicators were collected on day 4 of mechanical ventilation. By day 4, 668 patients received care under a high intensity staffing model (primary intensivist care or mandatory consult) and 193 patients received care under a low intensity staffing model (optional consultation or no intensivist). Among eligible patients, those receiving care under a high intensity staffing model were more likely to receive prophylaxis for deep vein thrombosis (risk ratio 1.08, 95% CI 1.00 to 1.17), stress ulcer prophylaxis (risk ratio 1.10, 95% CI 1.03 to 1.18), a spontaneous breathing trial (risk ratio 1.37, 95% CI 0.97 to 1.94), interruption of sedation (risk ratio 1.64, 95% CI 1.13 to 2.38) and intensive insulin treatment (risk ratio 1.40, 95% CI 1.18 to 1.79) on day 4 of mechanical ventilation. Models accounting for clustering by hospital produced similar estimates of the staffing effect, except for prophylaxis against thrombosis and stress ulcers.

CONCLUSIONS

High intensity physician staffing is associated with increased use of evidence-based quality indicators in patients receiving mechanical ventilation.

Intensivist physician staffing and the process of care in academic medical centres

BACKGROUND

Although intensivist physician staffing is associated with improved outcomes in critical care, little is known about the mechanism leading to this observation.

OBJECTIVE

To determine the relationship between intensivist staffing and select process-based quality indicators in the intensive care unit.

RESEARCH DESIGN

Retrospective cohort study in 29 academic hospitals participating in the University HealthSystem Consortium Mechanically Ventilated Patient Bundle Benchmarking Project.

PATIENTS

861 adult patients receiving prolonged mechanical ventilation in an intensive care unit.

RESULTS

Patient-level information on physician staffing and process-of-care quality indicators were collected on day 4 of mechanical ventilation. By day 4, 668 patients received care under a high intensity staffing model (primary intensivist care or mandatory consult) and 193 patients received care under a low intensity staffing model (optional consultation or no intensivist). Among eligible patients, those receiving care under a high intensity staffing model were more likely to receive prophylaxis for deep vein thrombosis (risk ratio 1.08, 95% CI 1.00 to 1.17), stress ulcer prophylaxis (risk ratio 1.10, 95% CI 1.03 to 1.18), a spontaneous breathing trial (risk ratio 1.37, 95% CI 0.97 to 1.94), interruption of sedation (risk ratio 1.64, 95% CI 1.13 to 2.38) and intensive insulin treatment (risk ratio 1.40, 95% CI 1.18 to 1.79) on day 4 of mechanical ventilation. Models accounting for clustering by hospital produced similar estimates of the staffing effect, except for prophylaxis against thrombosis and stress ulcers.

CONCLUSIONS

High intensity physician staffing is associated with increased use of evidence-based quality indicators in patients receiving mechanical ventilation.

Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change

BACKGROUND

Nosocomial infections occur in approximately 10% of patients in intensive care units (ICUs). Several studies have shown that a quality improvement initiative can reduce nosocomial infections, mortality, and cost.

CONTEXT

Our hospital is located in Northern Mississippi and has a 28 bed Medical-Surgical ICU unit with 95% occupancy. We joined the ICU collaborative with the IMPACT initiative of the Institute of Healthcare Improvement (IHI) in October 2002. A preliminary prospective before (fiscal year (FY) 2001-2) and after (FY 2003) hypothesis generating study was conducted of outcomes resulting from small tests of change in the management of ICU patients.

KEY MEASURES FOR IMPROVEMENT

Nosocomial infection rates, adverse events per ICU day, average length of stay, and average cost per ICU episode.

STRATEGY FOR CHANGE

Four changes were implemented: (1) physician led multidisciplinary rounds; (2) daily "flow" meeting to assess bed availability; (3) "bundles" (sets of evidence based best practices); and (4) culture changes with a focus on the team decision making process.

EFFECTS OF CHANGE

Between baseline and re-measurement periods, nosocomial infection rates declined for ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p = 0.04) and bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = 0.03), with a downward trend in the rate of urinary tract infections (from 3.8 to 2.4 per 1000 catheter days, p = 0.17). There was a strong downward trend in the rates of adverse events in the ICU as well as the average length of stay per episode. From FY 2002 to FY 2003 the cost per ICU episode fell from $3406 to $2973.

LESSONS LEARNED

A systematic approach through collaboration with IHI's IMPACT initiative may have contributed to significant improvements in care in the ICU setting. Multidisciplinary teams appeared to improve communication, and bundles provided consistency of evidence based practices. The flow meetings allowed for rapid prioritization of activity and a new decision making culture empowered team members. The impact of these changes needs to be assessed more widely using rigorous study designs.

Effect of fatigue, workload, and environment on patient safety in the pediatric intensive care unit

INTRODUCTION

Pediatric intensive care unit patient care occurs in an unpredictable, technology-rich environment that is dependent on highly skilled providers who need constant communication-all features providing the setting for potential error. This review examines basic principles of human error and sleep physiology and evaluates the evidence for potential effects of fatigued healthcare workers and workload on medical error. BODY: The pediatric intensive care unit setting, examined from a human factors engineering standpoint, is a highly complex environment in which fatigue and excessive workload can provide potential "holes" that may allow errors to occur. A large body of evidence is examined that suggests sleep deprivation can impair medical and surgical performance and can be improved with scheduling intervention. Nursing fatigue and workload have documented effects on increasing intensive care unit error, infections, and cost. Specific environmental factors such as distractions and communication barriers are also associated with greater error.

CONCLUSION

Fatigue, excessive workload, and the pediatric intensive care unit environment can adversely affect the performance of physicians and nurses working in the pediatric intensive care unit. The weight of the evidence suggests that these factors have the potential to contribute to medical error in the pediatric intensive care unit.

Hospital volume and the outcomes of mechanical ventilation

BACKGROUND

An increased volume of patients is associated with improved survival in numerous high-risk medical and surgical conditions. The relationship between the number of patients admitted (hospital volume) and outcome among patients with critical illnesses is unknown.

METHODS

We analyzed data from 20,241 nonsurgical patients receiving mechanical ventilation at 37 acute care hospitals in the Acute Physiology and Chronic Health Evaluation clinical information system from 2002 through 2003. Multivariate analyses were performed to adjust for the severity of illness and other differences in the case mix.

RESULTS

An increase in hospital volume was associated with improved survival among patients receiving mechanical ventilation in the intensive care unit (ICU) and in the hospital. Admission to a hospital in the highest quartile according to volume (i.e., >400 patients receiving mechanical ventilation per year) was associated with a 37 percent reduction in the adjusted odds of death in the ICU as compared with admission to hospitals in the lowest quartile (< or =150 patients receiving mechanical ventilation per year, P<0.001). In-hospital mortality was similarly reduced (adjusted odds ratio, 0.66; 95 percent confidence interval, 0.52 to 0.83; P<0.001). A typical patient in a hospital in a low-volume quartile would have an adjusted in-hospital mortality of 34.2 percent as compared with 25.5 percent in a hospital in a high-volume quartile. Among survivors, there were no significant trends in the length of stay in the ICU or the hospital.

CONCLUSIONS

Mechanical ventilation of patients in a hospital with a high case volume is associated with reduced mortality. Further research is needed to determine the mechanism of the relationship between volume and outcome among patients with a critical illness.

A systematic review of the literature on multidisciplinary rounds to design information technology

Multidisciplinary rounds (MDR) have become important mechanisms for communication and coordination of care. To guide design of tools supporting MDR, we reviewed the literature published from 1990 to 2005 about MDR on information tools used, information needs, impact of information tools, and evaluation measures. Fifty-one papers met inclusion criteria and were included. In addition to patient-centric information tools (e.g., medical chart) and decision-support tools (e.g., clinical pathway), process-oriented tools (e.g., rounding list) were reported to help with information organization and communication. Information tools were shown to improve situation awareness of multidisciplinary care providers, efficiency of MDR, and length of stay. Communication through MDR may be improved by process-oriented information tools that help information organization, communication, and work management, which could be achieved through automatic extraction from clinical information systems, displays and printouts in condensed forms, at-a-glance representations of the care unit, and storing work-process information temporarily.

The enhanced postoperative care system

The perioperative care system is a continuum that includes preoperative patient evaluation, operating room scheduling, the operation itself, and postoperative care. This costly fast-paced system requires its various components to function efficiently and interact effectively. This review explores the interrelation between the operational elements of the enhanced care postoperative care system (intensive care units, intermediate care units, postanesthesia care units, and monitored floor beds) and other perioperative care activities. This care system provides patients with enhanced (from routine floor) nursing and medical care, continuous physiological monitoring, and sophisticated treatments (eg, continuous infusion of vasoactive substances). A management, rather than clinical, approach is used to provide insight into the operations of the perioperative care system so that bottlenecks to patient flow may be identified and eliminated. Emphasis is placed on the need to switch from a "fiefdom" mentality, where each component of the system acts independently and defensively, to systems thinking, in which complex interrelated patterns are identified, analyzed, and optimized.

The dying patient in the ICU: role of the interdisciplinary team

Expert opinion supports the application of broad interdisciplinary team approaches to the care of the dying patient in the intensive care unit (ICU). Current literature contains many suggestions about how core team members-physicians, nurses, and patients/family members-could systematically enhance interdisciplinary collaboration in the care of the dying patient. In the few studies of ICU interdisciplinary collaborative care of the dying patient, investigator shave demonstrated improvement in care. In addition, ethics consultants and interdisciplinary palliative care teams, working with the core team members, have improved care for the dying. Further studies are needed to document alternative interdisciplinary models for achieving improved and durable patient, family,and provider outcomes in the care of the dying ICU patient.

Evaluating ventilator weaning best practice: a long-term acute care hospital system-wide quality initiative

Long-term acute care (LTAC) hospitals and units are becoming increasingly important to the management of patients who have serious, complex critical illnesses and require mechanical ventilation for extended periods of time. Kindred Healthcare, Inc., a nation-wide system of LTAC hospitals embarked on a quality initiative to establish a Ventilator Management and Weaning Best Practice. The process steps included: measurement of performance of all hospitals in the system using a risk-adjusted methodology to evaluate clinical outcomes, identification of facilities with superior outcomes; structured evaluation of the characteristics, practices, and protocols of these Best Practice hospitals; and utilization of the information gleaned from these hospitals to establish evidence-based LTAC best practice ventilator management guidelines. Key characteristics of the Best Practice LTAC hospitals were: hospital-wide philosophy that "everybody weans"-that is, all disciplines actively participate and all patients are expected to wean; collaborative multidisciplinary plans of care; a consistent and a 24-hour-a-day approach to ventilator management and weaning; daily communication; mutual respect for the contributions of all disciplines to the weaning process; early, aggressive nutrition support and intervention by rehabilitation services; use of 24-hour in-hospital advance practice nurses, hospitalists, or physician assistants; and intervention by physiatrists.

Qualitative review of intensive care unit quality indicators

PURPOSE

The purpose of this study was to (1) conduct a systematic review of the literature to identify interventions that improve patient outcomes in the intensive care unit (ICU); (2) evaluate potential measures of quality based on the impact, feasibility, variability, and the strength of evidence to support each measure and to categorize these measures as outcome, process, access, or complication measures; and (3) select a list of candidate quality measures that can be broadly applied to improve ICU care.

METHODS

We identified and independently reviewed all studies in Medline (1965-2000) and The Cochrane Library (Issue 3, 2001) that met the following criteria: design: observational studies, experimental trials, or systematic reviews; population: critically ill adults; and intervention: process or structure measure that was associated with improved patient outcomes: morbidity, mortality, complications, errors, costs, length of stay (LOS), and patient reported outcomes. Studies were grouped into categories by the type of outcome that was improved by the intervention. Potential quality measures were evaluated for: impact on morbidity, mortality, and costs; feasibility of the measure; and variability in the measure. We evaluated the strength of evidence for each intervention used to improve outcomes and using the Delphi method, assigned an over-all recommendation for each quality measure.

RESULTS

A total of 3,014 citations were identified. Sixty-six studies that met selection criteria reported on a variety of interventions that were associated with improved patient outcomes. We identified 6 outcome measures: ICU mortality rate, ICU LOS greater than 7 days, average ICU LOS, average days on mechanical ventilation, suboptimal management of pain, and patient/family satisfaction; 6 process measures: effective assessment of pain, appropriate use of blood transfusions, prevention of ventilator-associated pneumonia, appropriate sedation, appropriate peptic ulcer disease prophylaxis, and appropriate deep venous thrombosis prophylaxis; 4 access measures: rate of delayed admissions, rate of delayed discharges, cancelled surgical cases, and emergency department by-pass hours; and 3 complication measures: rate of unplanned ICU readmission, rate of catheter-related blood stream infections, and rate of resistant infections.

CONCLUSIONS

Further work is needed to create operational definitions and to pilot test the selected measures. The value of these measures will be determined by our ability to evaluate our current performance and implement interventions designed to improve the quality of ICU care.

Variation in intensive care unit outcomes: a search for the evidence on organizational factors

This study was undertaken to determine the extent of empirical evidence on the role of organizational factors in the critical care literature and to categorize these factors. Studies evaluating organizational factors were identified through electronic and hand searching of the critical care literature. Sixty-three publications relating to 54 different studies were identified. The studies were grouped into eight main categories: staffing, teamwork, volume and pressure of work, protocols, admission to intensive care, technology, structure, and error. Studies evaluating organizational factors exist in the critical care literature, and there is evidence that the number is increasing each year. Results indicate that organizational factors may have an impact on mortality after case mix adjustment. Some areas have been investigated more thoroughly than others and are ripe for systematic review. Variation in case mix adjusted hospital mortality after intensive care is an old theme. This study has shown that emerging data will help us understand mortality differences and deliver better outcomes for patients.

Practising evidence-based medicine: the design and implementation of a multidisciplinary team-driven extubation protocol

BACKGROUND

Evidence from recent literature shows that protocol-directed extubation is a useful approach to liberate patients from mechanical ventilation (MV). However, research evidence does not necessarily provide guidance on how to implement changes in individual intensive care units (ICUs). We conducted the present study to determine whether such an evidence-based strategy can be implemented safely and effectively using a multidisciplinary team (MDT) approach.

METHOD

We designed a MDT-driven extubation protocol. Multiple meetings were held to encourage constructive criticism of the design by attending physicians, nurses and respiratory care practitioners (RCPs), in order to define a protocol that was evidence based and acceptable to all clinical staff involved in the process of extubation. It was subsequently implemented and evaluated in our medical/ surgical ICU. Outcomes included response of the MDT to the initiative, duration of MV and stay in the ICU, as well as reintubation rate.

RESULTS

The MDT responded favourably to the design and implementation of this MDT-driven extubation protocol, because it provided greater autonomy to the staff. Outcomes reported in the literature and in the historical control group were compared with those in the protocol group, and indicated similar durations of MV and ICU stay, as well as reintubation rates. No adverse events were documented.

CONCLUSION

An MDT approach to protocol-directed extubation can be implemented safely and effectively in a multidisciplinary ICU. Such an effort is viewed favourably by the entire team and is useful in enhancing team building.