Role of organization ethics in critical care medicine

How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective

BACKGROUND

The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements.

METHODS

Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis.

RESULTS

An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care.

CONCLUSIONS

To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.

Complexity Sciences

Complexity sciences, in plain English, are the sciences of interconnectedness.

The aim of complexity sciences is to understand the many different facets of phenomena. Complexity sciences employs a variety of different methodological approaches to describe and to analyse multifaceted phenomena like health, the economy, or environmental systems.

Basically, a system consists of a number of parts that are connected to each other. Systems differ depending on the nature of their connectedness. Simple systems have one-to-one relationships and their behaviour is precisely predictable. Complicated systems have one-to-many relationships with mostly predictable behaviours.

This book deals with complex adaptive systems with many-to-many relationships. Their many-to-many relationships make their behaviour emergent, hence their outcomes are unpredictable. Complex adaptive systems have a special characteristic, the members of the system can learn from feedback and experiences. The relationships in complex adaptive systems change constantly allowing the system to evolve over time in light of changing demands. However, a system’s overall behaviour, despite its adaptation to changing circumstances, remains relatively stable within boundaries, but occasionally, its behaviour may change abruptly and dramatically for no apparent reason.

One can compare the behaviour of complex adaptive systems to that of a family; most of the time a family stays together despite ups and downs, but occasionally a family can abruptly break apart to the surprise of its members and its surroundings.

Another important characteristic of complex adaptive systems is its nonlinear behaviour to change, i.e. the magnitude of change in one member of the system shows a disproportional change in that of others. As experience shows, small changes in the behaviour of a system member often show dramatic changes in the behaviour of the whole system, whereas a major change in the behaviour of that member typically results in little or no change.

Studying complex adaptive systems aims to understand the relationships and the dynamics between the members of the systems. This understanding allows for better responses when the system as a whole is challenged by constraints and/or unfamiliar challenges.

A special characteristic of social systems is their “goal-delivering” nature. In organisational terms these are codified by their purpose, goals, and values statements.

Ethical problems in intensive care unit admission and discharge decisions: a qualitative study among physicians and nurses in the Netherlands

BACKGROUND

There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with.

METHODS

This was an explorative, descriptive study using qualitative methods (individual and focus group interviews). We conducted 19 individual interviews and 4 focus group interviews with nurses and physicians working in the ICU or the general ward of 10 Dutch hospitals.

RESULTS

The ethical problems in the context of ICU admission and discharge can be divided into problems concerning full bed occupancy and problems related to treatment decisions. The gap between the high level of care the ICU can provide and the lower care level in the general ward sometimes leads to mutual misunderstandings. Our results indicate that when professionals of different wards feel there is a collective responsibility and effort to solve a problem, this helps to prevent or alleviate moral distress. ICU patients' wishes are often unknown, causing healthcare professionals to err on the side of more treatment. Additionally, the highly technological nature of intensive care appears to encourage over-treatment.

CONCLUSIONS

It is important for ICUs and general wards to communicate and cooperate well, since there is a mutual dependency for optimal patient flow between the different departments. Interventions that improve the understanding and cooperation between these wards may help mitigate ethical problems. The nature of the ICU environment makes it important for healthcare professionals to be aware of the risk of over-treatment, reflect on why they do what they do, and be mindful of a possible negative impact of over-treatment on their patients. Early discussion of a patient's wishes with regard to treatment options is important in preventing over-treatment.

Cost-effectiveness of histamine receptor-2 antagonist versus proton pump inhibitor for stress ulcer prophylaxis in critically ill patients*

OBJECTIVE

To examine the cost-effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis.

DESIGN

Decision analysis model examining costs and effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. Costs were expressed in 2012 U.S. dollars from the perspective of the institution and included drug regimens and the following outcomes: clinically significant stress-related mucosal bleed, ventilator-associated pneumonia, and Clostridium difficile infection. Effectiveness was the mortality risk associated with these outcomes and represented by survival. Costs, occurrence rates, and mortality probabilities were extracted from published data.

SETTING

A simulation model.

PATIENTS

A mixed adult ICU population.

INTERVENTIONS

Histamine receptor-2 antagonist or proton pump inhibitor for 9 days of stress ulcer prophylaxis therapy.

MAIN MEASUREMENTS AND RESULTS

Output variables were expected costs, expected survival rates, incremental cost, and incremental survival rate. Univariate sensitivity analyses were conducted to determine the drivers of incremental cost and incremental survival. Probabilistic sensitivity analysis was conducted using second-order Monte Carlo simulation. For the base case analysis, the expected cost of providing stress ulcer prophylaxis was $6,707 with histamine receptor-2 antagonist and $7,802 with proton pump inhibitor, resulting in a cost saving of $1,095 with histamine receptor-2 antagonist. The associated mortality probabilities were 3.819% and 3.825%, respectively, resulting in an absolute survival benefit of 0.006% with histamine receptor-2 antagonist. The primary drivers of incremental cost and survival were the assumptions surrounding ventilator-associated pneumonia and bleed. The probabilities that histamine receptor-2 antagonist was less costly and provided favorable survival were 89.4% and 55.7%, respectively. A secondary analysis assuming equal rates of C. difficile infection showed a cost saving of $908 with histamine receptor-2 antagonists, but the survival benefit of 0.0167% favored proton pump inhibitors.

CONCLUSIONS

Histamine receptor-2 antagonist therapy appears to reduce costs with survival benefit comparable to proton pump inhibitor therapy for stress ulcer prophylaxis. Ventilator-associated pneumonia and bleed are the variables most affecting these outcomes. The uncertainty in the findings justifies a prospective trial.

An ethical framework for developing and sustaining a healthy workplace

Acute and critical care nurses provide care that is intellectually challenging and physically demanding in environments that are often characterized by ethical concerns and dilemmas. As complex adaptive systems, these environments include nurses, physicians, social workers, chaplains, case managers, and administrators who interact together in situations of tremendous uncertainty and frequently in the face of professional or social disagreement about patient/family care, processes, and outcomes. Nurses' ability to identify and resolve concerns in such situations as part of a collaborative ethical climate is a significant retention factor and a hallmark of a healthy workplace. The purpose of this article is to describe a pluralist ethical framework that evolved from the formation of a healthy workplace and that may be integrated to sustain an ethical climate. Discussion of development of a healthy workplace employing participatory action research will be followed by a description of ethical theories supporting the framework and their relevance to creating and sustaining a healthy workplace and ethical practice environment. Finally, specific application examples of the ethical framework from nursing units' staff participatory action research studies will be presented.