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Woodbridge HR, Norton C, Jones M, Brett SJ, Alexander CM, Gordon AC. Clinician and patient perspectives on the barriers and facilitators to physical rehabilitation in intensive care: a qualitative interview study. BMJ Open 2023; 13:e073061. [PMID: 37940149 PMCID: PMC10632869 DOI: 10.1136/bmjopen-2023-073061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/29/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVES The objective of this study is to explore patient, relative/carer and clinician perceptions of barriers to early physical rehabilitation in intensive care units (ICUs) within an associated group of hospitals in the UK and how they can be overcome. DESIGN Qualitative study using semi-structured interviews and thematic framework analysis. SETTING Four ICUs over three hospital sites in London, UK. PARTICIPANTS Former ICU patients or their relatives/carers with personal experience of ICU rehabilitation. ICU clinicians, including doctors, nurses, physiotherapists and occupational therapists, involved in the delivery of physical rehabilitation or decisions over its initiation. PRIMARY AND SECONDARY OUTCOMES MEASURES Views and experiences on the barriers and facilitators to ICU physical rehabilitation. RESULTS Interviews were carried out with 11 former patients, 3 family members and 16 clinicians. The themes generated related to: safety and physiological concerns, patient participation and engagement, clinician experience and knowledge, teamwork, equipment and environment and risks and benefits of rehabilitation in intensive care. The overarching theme for overcoming barriers was a change in working model from ICU clinicians having separate responsibilities (a multidisciplinary approach) to one where all parties have a shared aim of providing patient-centred ICU physical rehabilitation (an interdisciplinary approach). CONCLUSIONS The results have revealed barriers that can be modified to improve rehabilitation delivery in an ICU. Interdisciplinary working could overcome many of these barriers to optimise recovery from critical illness.
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Affiliation(s)
- Huw R Woodbridge
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | | | - Stephen J Brett
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Caroline M Alexander
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Anthony C Gordon
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Armaignac DL, Ramamoorthy V, DuBouchet EM, Williams LM, Kushch NA, Gidel L, Badawi O. Descriptive Comparison of Two Models of Tele-Critical Care Delivery in a Large Multi-Hospital Health Care System. Telemed J E Health 2023; 29:1465-1475. [PMID: 36827094 DOI: 10.1089/tmj.2022.0415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Introduction: The Society of Critical Care Medicine Tele-Critical Care (TCC) Committee has identified the need for rigorous comparative research of different TCC delivery models to support the development of best practices for staffing, application, and approaches to workflow. Our objective was to describe and compare outcomes between two TCC delivery models, TCC with 24/7 Bedside Intensivist (BI) compared with TCC with Private Daytime Attending Intensivist (PI) in relation to intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), cost, and complications across the spectrum of routine ICU standards of care. Methods: Observational cohort study at large health care system in 12 ICUs and included patients, ≥18, with Acute Physiology and Chronic Health Evaluation (APACHE) IVa scores and predictions (October 2016-June 2019). Results: Of the 19,519 ICU patients, 71.7% (n = 13,993) received TCC with 24/7 BI while 28.3% (n = 5,526) received TCC with PI. ICU and Hospital mortality (4.8% vs. 3.1%, p < 0.0001; 12.6% vs. 8.1%, p < 0.001); and ICU and Hospital LOS (3.2 vs. 2.4 days, p < 0.001; 9.8 vs. 7.2 days, p < 0.001) were significantly higher among 24/7 BI compared with PI. The APACHE observed/expected ratios (odds ratio [OR]; 95% confidence interval [CI]) for ICU mortality (0.62; 0.58-0.67) vs. (0.53; 0.46-0.61) and Hospital mortality (0.95; 0.57-1.48) vs. (0.77; 0.70-0.84) were significantly different for 24/7 BI compared with PI. Multivariate mixed models that adjusted for confounders demonstrated significantly greater odds of (OR; 95% CI) ICU mortality (1.58; 1.28-1.93), Hospital mortality (1.52; 1.33-1.73), complications (1.55; 1.18-2.04), ICU LOS [3.14 vs. 2.59 (1.25; 1.19-1.51)], and Hospital LOS [9.05 vs. 7.31 (1.23; 1.21-1.25)] among 24/7 BI when compared with PI. Sensitivity analyses adjusting for ICU admission within 24 h of hospital admission, receiving active ICU treatments, nighttime admission, sepsis, and highest third acute physiology score indicated significantly higher odds for 24/7 BI compared with PI. Conclusion: Our comparison demonstrated that TCC delivery model with PI provided high-quality care with significant positive effects on outcomes. This suggests that TCC delivery models have broad-ranging applicability and benefits in routine critical care, thus necessitating progressive research in this direction.
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Affiliation(s)
- Donna Lee Armaignac
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
| | | | - Eduardo Martinez DuBouchet
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
- Wertheim School of Medicine, Florida International University, Miami, Florida, USA
| | - Lisa-Mae Williams
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
- Wertheim School of Medicine, Florida International University, Miami, Florida, USA
| | | | - Louis Gidel
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
| | - Omar Badawi
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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Anthony CM, Altman AH, Otte B, Mines MJ, Mazzoli RA, Lappan CM, Legault GL. Teleophthalmology in the United States Army: A Review From 2004 Through 2018. Mil Med 2023; 188:e182-e189. [PMID: 34865104 DOI: 10.1093/milmed/usab417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/22/2021] [Accepted: 09/28/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION We describe results of the U.S. Army Ocular Teleconsultation program from 2004 through 2018 as well as the current condition, benefits, barriers, and future opportunities for teleophthalmology in the clinical settings and disease areas specific to the U.S. Military. MATERIALS AND METHODS This was a retrospective, noncomparative, consecutive case series. A total of 653 ocular teleconsultations were reviewed; 76 concerned general policy questions and underwent initial screening to determine the year each request was received, the average and median initial consultant response time, the number of participating consultants, the country from which the request originated, the military status and branch of each U.S. patient for which a request was submitted, and the nationality, age, and military status of foreign patients for whom consults were requested. The remaining 577 requests were further analyzed to determine the diagnostic category of the request, whether or not an evacuation recommendation was provided by a consultant, the relationship of the request to trauma, if and what type of nonocular specialty consultant(s) participated in the consultation request, and if and what type of ancillary imaging accompanied the request. RESULTS The number of requests was 13 in 2004, compared to 80 in 2011 and 11 in 2018. The average response time in 2018 was 2.27 hours compared to 9. 73 hours in 2004. The number of participating ocular specialists was 5 in 2004, compared to 39 in 2013 and 13 in 2018. Requests originating from Iraq and Afghanistan comprised 61.1% (399/653) of requests. The U.S. Army personnel comprised the largest percentage of consults at 38.6% (252/653). Nonmilitary patients from the USA accounted for 18.5% (121/653) of consults. Non-U.S. patients including coalition forces, contractors, detainees, and noncombatants accounted for 14.4% (94/653) of consults, of which 22% (21/94) were children. Anterior segment consults accounted for 45.1% (260/577) of consults, with corneal surface disease being the largest subset within this diagnostic category. Evacuation was recommended in 22.7% (131/577) of overall cases and 41.1% (39/95) of trauma cases. Requests were associated with either combat-related or accidental trauma in 16.5% (95/577) of cases. Dermatology and neurology were the most commonly co-consulted specialties, representing 40.0% (32/80) and 33.75% (27/80) of consults, respectively. Photographs of suspected ocular pathology accompanied 37.4% of consults, with the likelihood requesters included photographs being greatest in cases involving pediatric ophthalmology (7/9, 77.8%) and oculoplastics (86/120, 71.7%). CONCLUSIONS Army teleophthalmology has been an indispensable resource in supporting and advancing military medicine, helping to optimize the quality, efficiency, and accessibility of ophthalmic care for U.S. Military personnel, beneficiaries, allied forces, and local nationals worldwide. A dedicated ophthalmic care and coordination system which utilizes new advances in teleconsultation technology could further enhance our current capability to care for the ophthalmic needs of patients abroad, with opportunity for improving domestic care as well.
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Affiliation(s)
- Christopher M Anthony
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Adam H Altman
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Benjamin Otte
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Michael J Mines
- Ophthalmology Service, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 20762, USA
| | - Robert A Mazzoli
- Department of Surgery, Division of Ophthalmology, Uniformed Services University, Bethesda, MD 20814, USA.,Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD 98431, USA
| | - Charles M Lappan
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Gary L Legault
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA.,Department of Surgery, Division of Ophthalmology, Uniformed Services University, Bethesda, MD 20814, USA
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Lilly CM, Cucchi E, Marshall N, Katz A. Battling Intensivist Burnout. Chest 2019; 156:1001-1007. [DOI: 10.1016/j.chest.2019.04.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 04/03/2019] [Accepted: 04/25/2019] [Indexed: 11/15/2022] Open
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Hoonakker PLT, Carayon P. Work System Barriers and Strategies Reported by Tele-Intensive Care Unit Nurses: A Case Study. Crit Care Nurs Clin North Am 2018; 30:259-271. [PMID: 29724444 DOI: 10.1016/j.cnc.2018.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Tele-intensive care units (ICUs) are an innovation to handle issues such as personnel shortage and improving care. In tele-ICUs, clinical teams monitor ICU patients remotely and support clinicians in multiple ICUs. The tele-ICU and ICU clinicians function as virtual teams. Little is known how these teams function and what challenges they encounter. We examined the challenges from the perspective of nurses in a tele-ICU. We used a case study design and conducted interviews with 10 tele-ICU nurses. The nurses encounter challenges in interacting with the multiple ICUs that they monitor remotely and have developed strategies to cope with these challenges.
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Affiliation(s)
- Peter L T Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3124 Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706, USA.
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3126 Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706, USA
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Lilly CM, Motzkus C, Rincon T, Cody SE, Landry K, Irwin RS. ICU Telemedicine Program Financial Outcomes. Chest 2016; 151:286-297. [PMID: 27932050 DOI: 10.1016/j.chest.2016.11.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 10/14/2016] [Accepted: 11/15/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND ICU telemedicine improves access to high-quality critical care, has substantial costs, and can change financial outcomes. Detailed information about financial outcomes and their trends over time following ICU telemedicine implementation and after the addition of logistic center function has not been published to our knowledge. METHODS Primary data were collected for consecutive adult patients of a single academic medical center. We compared clinical and financial outcomes across three groups that differed regarding telemedicine support: a group without ICU telemedicine support (pre-ICU intervention group), a group with ICU telemedicine support (ICU telemedicine group), and an ICU telemedicine group with added logistic center functions and support for quality-care standardization (logistic center group). The primary outcome was annual direct contribution margin defined as aggregated annual case revenue minus annual case direct costs (including operating costs of ICU telemedicine and its related programs). All monetary values were adjusted to 2015 US dollars using Producer Price Index for Health-Care Facilities. RESULTS Annual case volume increased from 4,752 (pre-ICU telemedicine) to 5,735 (ICU telemedicine) and 6,581 (logistic center). The annual direct contribution margin improved from $7,921,584 (pre-ICU telemedicine) to $37,668,512 (ICU telemedicine) to $60,586,397 (logistic center) due to increased case volume, higher case revenue relative to direct costs, and shorter length of stay. CONCLUSIONS The ability of properly modified ICU telemedicine programs to increase case volume and access to high-quality critical care with improved annual direct contribution margins suggests that there is a financial argument to encourage the wider adoption of ICU telemedicine.
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Affiliation(s)
- Craig M Lilly
- Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA; Department of Anesthesiology and Surgery, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA; Clinical and Population Health Research Program, UMass Memorial Medical Center, Worcester, MA; Graduate School of Biomedical Sciences, UMass Memorial Medical Center, Worcester, MA.
| | - Christine Motzkus
- Clinical and Population Health Research Program, UMass Memorial Medical Center, Worcester, MA
| | - Teresa Rincon
- Department of Nursing, UMass Memorial Medical Center, Worcester, MA
| | - Shawn E Cody
- UMass Memorial Health Care, UMass Memorial Medical Center, Worcester, MA; Department of Nursing, UMass Memorial Medical Center, Worcester, MA
| | - Karen Landry
- UMass Memorial Health Care, UMass Memorial Medical Center, Worcester, MA
| | - Richard S Irwin
- Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA; Graduate School of Nursing Sciences, UMass Memorial Medical Center, Worcester, MA
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Martínez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest 2016; 151:579-585. [PMID: 27818327 DOI: 10.1016/j.chest.2016.10.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Overuse of arterial blood gas (ABG) determinations leads to increased costs, inefficient use of staff work hours, and patient discomfort and blood loss. We developed guidelines to optimize ABG use in the ICU. METHODS ABG use guidelines were implemented in all adult ICUs in our institution: three medical, two trauma-surgery, one cardiovascular, and one neurosurgical ICU. Although relying on pulse oximetry, we encouraged the use of ABG determination after an acute respiratory event or for a rational clinical concern and discouraged obtaining ABG measurements for routine surveillance, after planned changes of positive end-expiratory pressure or Fio2 on the mechanical ventilator, for spontaneous breathing trials, or when a disorder was not suspected. ABG measurements and global ICU metrics were collected before (year 2014) and after (year 2015) the intervention. RESULTS We saw a reduction of 821.5 ± 257.4 ABG determinations per month (41.5%), or approximately one ABG determination per patient per mechanical ventilation (MV) day for each month (43.1%), after introducing the guidelines (P < .001). This represented 49 L of saved blood, a reduction of $39,432 in the costs of ICU care, and 1,643 staff work hours freed for other tasks. Appropriately indicated tests rose to 83.4% from a baseline 67.5% (P = .002). Less than 5% of inappropriately indicated ABG determinations changed patient management in the postintervention period. There were no significant differences in MV days, severity of illness, or ICU mortality between the two periods. CONCLUSIONS The large scale implementation of guidelines for ABG use reduced the number of inappropriately ordered ABG determinations over seven different multidisciplinary ICUs, without negatively impacting patient care.
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Affiliation(s)
- Carlos D Martínez-Balzano
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Paulo Oliveira
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Michelle O'Rourke
- Department of Nursing, UMass Memorial Healthcare Center, Worcester, MA
| | - Luanne Hills
- Department of Respiratory Care, UMass Memorial Healthcare Center, Worcester, MA
| | - Andrés F Sosa
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA.
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Critical Care Medicine Beds, Use, Occupancy, and Costs in the United States: A Methodological Review. Crit Care Med 2016; 43:2452-9. [PMID: 26308432 DOI: 10.1097/ccm.0000000000001227] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article is a methodological review to help the intensivist gain insights into the classic and sometimes arcane maze of national databases and methodologies used to determine and analyze the ICU bed supply, use, occupancy, and costs in the United States. Data for total ICU beds, use, and occupancy can be derived from two large national healthcare databases: the Healthcare Cost Report Information System maintained by the federal Centers for Medicare and Medicaid Services and the proprietary Hospital Statistics of the American Hospital Association. Two costing methodologies can be used to calculate U.S. ICU costs: the Russell equation and national projections. Both methods are based on cost and use data from the national hospital datasets or from defined groups of hospitals or patients. At the national level, an understanding of U.S. ICU bed supply, use, occupancy, and costs helps provide clarity to the width and scope of the critical care medicine enterprise within the U.S. healthcare system. This review will also help the intensivist better understand published studies on administrative topics related to critical care medicine and be better prepared to participate in their own local hospital organizations or regional critical care medicine programs.
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Critical Care Organizations in Academic Medical Centers in North America: A Descriptive Report. Crit Care Med 2015; 43:2239-44. [PMID: 26262950 DOI: 10.1097/ccm.0000000000001200] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES With the exception of a few single-center descriptive reports, data on critical care organizations are relatively sparse. The objectives of our study were to determine the structure, governance, and experience to date of established critical care organizations in North American academic medical centers. DESIGN A 46-item survey questionnaire was electronically distributed using Survey Monkey to the leadership of 27 identified critical care organizations in the United States and Canada between September 2014 and February 2015. A critical care organization had to be headed by a physician and have primary governance over the majority, if not all, of the ICUs in the medical center. MEASUREMENTS AND MAIN RESULTS We received 24 responses (89%). The majority of the critical care organizations (83%) were called departments, centers, systems, or operations committees. Approximately two thirds of respondents were from larger (> 500 beds) urban institutions, and nearly 80% were primary university medical centers. On average, there were six ICUs per academic medical center with a mean of four ICUs under critical care organization governance. In these ICUs, intensivists were present in-house 24/7 in 49%; advanced practice providers in 63%; hospitalists in 21%; and telemedicine coverage in 14%. Nearly 60% of respondents indicated that they had a separate hospital budget to support data management and reporting, oversight of their ICUs, and rapid response teams. The transition from the traditional model of ICUs within departmentally controlled services or divisions to a critical care organization was described as gradual in 50% and complete in only 25%. Nearly 90% indicated that their critical care organization governance structure was either moderately or highly effective; a similar number suggested that their critical care organizations were evolving with increasing domain and financial control of the ICUs at their respective institutions. CONCLUSIONS Our survey of the very few critical care organizations in North American academic medical centers showed that the governance models of critical care organizations vary and continue to evolve. Additional studies are warranted to improve our understanding of the factors that can foster the growth of critical care organizations and how they can be effective.
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Lui JK, Philbin M, Lau S, Philip PA, Yazdani M, Hatem D. Interprofessionalism between physicians and nurses: Moving forward. Int J Nurs Stud 2015; 52:1785-8. [DOI: 10.1016/j.ijnurstu.2015.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/13/2015] [Accepted: 09/15/2015] [Indexed: 10/23/2022]
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Research Advances in Critical Care: Targeting Patients' Physiological and Psychological Outcomes. BIOMED RESEARCH INTERNATIONAL 2015; 2015:283067. [PMID: 26587534 PMCID: PMC4637439 DOI: 10.1155/2015/283067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/14/2015] [Indexed: 11/17/2022]
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Chaves NJ, Ingram RJ, MacIsaac CM, Buising KL. Sticking to minimum standards: implementing antibiotic stewardship in intensive care. Intern Med J 2015; 44:1180-7. [PMID: 25070720 DOI: 10.1111/imj.12539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 07/20/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND In Australia, antimicrobial stewardship programmes are a compulsory component of hospital accreditation. Good documentation around anti-microbial prescribing aids communication and can improve prescribing practice in environments with multiple decision makers. AIM This study aims to develop and implement an intervention to improve antimicrobial prescribing practice in a 24-bed intensive care unit in a tertiary referral adult hospital. METHODS We conducted a four-phase (observation, reflection, implementation, evaluation) prospective collaborative before-after quality improvement study. Baseline audits and surveys of antimicrobial prescribing practices identified barriers to and enablers of good prescribing practice. A customised intervention was then implemented over 6 weeks and included a yellow medication record sticker, quarterly education sessions and intensive care unit-specific empiric antimicrobial prescribing guidelines. Post-implementation, the effects were monitored by serial antimicrobial prescribing audits for 1 year. The primary outcomes were clear documentation of the start date, the planned stop date or review date and the indication for an antibiotic. These were all considered the 'minimum standards' for an antimicrobial prescription on the medication record. RESULTS Documentation of minimum standards specifically addressed by the sticker improved (start date (72% to 90%, P < 0.001), stop date (16% to 63%, P < 0.001), antimicrobial indication documented on medication chart (58% to 83%, P < 0.01)). Overall, adherence to all three minimum standards (start date, stop date and indication) improved from 41/306 (13%) to 306/492 (63%) (P < 0.001). One-year post-implementation, the yellow sticker had become embedded into daily practice. CONCLUSION A systematic approach to quality improvement combined with the implementation of a tailored, multi-faceted intervention can improve antimicrobial prescribing practices.
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Affiliation(s)
- N J Chaves
- Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia
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van Sambeeck SJ, Martens SJ, Hundscheid T, Janssen EJ, Vos GD. Dutch paediatrician's opinions about acute care for critically ill children in general hospitals. Eur J Pediatr 2015; 174:607-13. [PMID: 25339423 DOI: 10.1007/s00431-014-2439-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 10/05/2014] [Accepted: 10/08/2014] [Indexed: 12/21/2022]
Abstract
UNLABELLED Paediatricians in general hospitals have limited experience with critically ill children, due to the low incidence and their diversity in age, pathology and presentation. Consequently, adequate organization, training and materials and medication are of major importance. This voluntary and anonymous survey-based study was conducted to gain insight in the current status of these aspects. In June 2012, all 687 paediatricians employed at 84 general hospitals in The Netherlands received a hardcopy questionnaire with questions relating to demographics, organization, training and materials and medication concerning the acute care for critically ill children. Of the sent questionnaires, 41.3% were eligible for analysis. According to the organization of the acute care of critically ill children, 73.9% of the respondents indicated verbal agreements were made, of which 77.0% stated that these were recorded in written protocols. Taskforces were present according to 64.5% of our respondents. Of the respondents, 64.4% were Advanced Paediatric Life Support (APLS) certified. Of the stated training scenarios, 90.8% were available in their hospital, which were followed on a regular basis by 63.9% of the paediatricians. Paediatric resuscitation carts were present on both emergency department and paediatric ward according to 95.1%. Materials (37.7%) and medication (45.3%) were frequently lacking. CONCLUSION Paediatricians from general hospitals in The Netherlands consider that acute care for critically ill children has to be improved in terms of organization, training and teamwork, and medication and materials. National guidelines concerning the organization and training may contribute to this improvement, as well as a standardized inventory list for paediatric resuscitation carts.
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Affiliation(s)
- Sam J van Sambeeck
- Department of Pediatrics, Division of Pediatric Intensive Care, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands,
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The authors reply. Crit Care Med 2015; 43:e61-2. [PMID: 25599510 DOI: 10.1097/ccm.0000000000000775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nierhaus A, de Heer G, Kluge S. [Concept for a department of intensive care]. Med Klin Intensivmed Notfmed 2014; 109:509-15. [PMID: 25270718 DOI: 10.1007/s00063-013-0345-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 09/02/2014] [Indexed: 02/16/2023]
Abstract
BACKGROUND Demographic change and increasing complexity are among the reasons for high-tech critical care playing a major and increasing role in today's hospitals. At the same time, intensive care is one of the most cost-intensive departments in the hospital. PREREQUISITES To guarantee high-quality care, close cooperation of specialised intensive care staff with specialists of all other medical areas is essential. A network of the intensive care units within the hospital may lead to synergistic effects concerning quality of care, simultaneously optimizing the use of human and technical resources. GOAL Notwithstanding any organisational concepts, development and maintenance of the highest possible quality of care should be of overriding importance.
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Affiliation(s)
- A Nierhaus
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland,
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Fortis S, Weinert C, Bushinski R, Koehler AG, Beilman G. A Health System-Based Critical Care Program with a Novel Tele-ICU: Implementation, Cost, and Structure Details. J Am Coll Surg 2014; 219:676-83. [DOI: 10.1016/j.jamcollsurg.2014.04.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/15/2014] [Accepted: 04/29/2014] [Indexed: 12/27/2022]
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Yoo EJ, Edwards JD, Dean ML, Dudley RA. Multidisciplinary Critical Care and Intensivist Staffing: Results of a Statewide Survey and Association With Mortality. J Intensive Care Med 2014; 31:325-32. [PMID: 24825859 DOI: 10.1177/0885066614534605] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 03/05/2014] [Indexed: 12/15/2022]
Abstract
PURPOSE The role of multidisciplinary teams in improving the care of intensive care unit (ICU) patients is not well defined, and it is unknown whether the use of such teams helps to explain prior research suggesting improved mortality with intensivist staffing. We sought to investigate the association between multidisciplinary team care and survival of medical and surgical patients in nonspecialty ICUs. MATERIALS AND METHODS We conducted a community-based, retrospective cohort study of data from 60 330 patients in 181 hospitals participating in a statewide public reporting initiative, the California Hospital Assessment and Reporting Taskforce (CHART). Patient-level data were linked with ICU organizational data collected from a survey of CHART hospital ICUs between December 2010 and June 2011. Clustered logistic regression was used to evaluate the independent effect of multidisciplinary care on the in-hospital mortality of medical and surgical ICU patients. Interactions between multidisciplinary care and intensity of physician staffing were examined to explore whether team care accounted for differences in patient outcomes. RESULTS After adjustment for patient characteristics and interactions, there was no association between team care and mortality for medical patients. Among surgical patients, multidisciplinary care was associated with a survival benefit (odds ratio 0.79; 95% confidence interval (CI), 0.62-1.00; P = .05). When stratifying by intensity of physician staffing, although the lowest odds of death were observed for surgical patients cared for in ICUs with multidisciplinary teams and high-intensity staffing (odds ratio, 0.77; 95% CI, 0.55-1.09; P = .15), followed by ICUs with multidisciplinary teams and low-intensity staffing (odds ratio 0.84, 95% CI 0.65-1.09, p = 0.19), these differences were not statistically significant. CONCLUSIONS Our results suggest that multidisciplinary team care may improve outcomes for critically ill surgical patients. However, no relationship was observed between intensity of physician staffing and mortality.
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Affiliation(s)
- Erika J Yoo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Jeffrey D Edwards
- Division of Pediatric Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Mitzi L Dean
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - R Adams Dudley
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
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