Management strategies to effect change in intensive care units: lessons from the world of business. Part III. Effectively effecting and sustaining change

The Quality Improvement Fellow: Educating on Making the Difference

The critical care medicine (CCM) fellowship is an opportunity for advanced anesthesiology trainees to refine their quality improvement (QI) skills. However, the short training period and inconsistent curricula make this challenging. The QI fellow (QIF) is described as an education program to provide consistent QI training during the CCM fellowship. The QIF is a mentored position to help manage data review, QI conferences, and improvement efforts within the CCM Division. The curriculum is focused on a QI education framework and mentored experiential learning. The QIF program is an opportunity for education and mentorship in the role of a CCM operational leader.

Assessing the Impact of Nasotracheal Intubation on Postoperative Neonates With Congenital Heart Disease: A Quality Improvement Project at a Single Heart Center

OBJECTIVES

Nasotracheal intubation (NTI) is associated with fewer unplanned extubations and improved oral motor skills compared with orotracheal intubation (OTI). Our study aimed to implement a practice change from OTI to NTI for neonatal cardiac surgery and assess impact on postoperative outcomes.

DESIGN

Single-center, prospective, quality improvement study.

SETTING

Academic children's hospital.

PATIENTS

One hundred thirty neonates undergoing cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

NTI during index cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

Data were collected between January 2019 and April 2021. The study was implemented in three phases: retrospective: OTI neonates ( n = 43), I: safety and feasibility of NTI ( n = 17), and II: speech language pathology (SLP) evaluation on postoperative day 1 facilitated by NTI ( n = 70). Retrospective and phase I patients were combined for analysis. Groups were compared using Kruskal-Wallis test or Wilcoxon rank-sum test.Ninety-one percent of eligible neonates were nasotracheally intubated. There were no clinically significant complications. Days to first SLP encounter decreased from a median 4.5 days (interquartile range [IQR], 3.8-6.2) to 1.1 days (IQR, 1.0-1.9; p < 0.001). Oral readiness time decreased from a median of 6.6 days (IQR, 5.4-8.9) to 4.3 days (IQR, 3.4-8.6; p < 0.001). .

CONCLUSIONS

NTI is feasible and safe in neonatal cardiac surgery. System-level engagement with stakeholders is necessary to change clinical practice. NTI facilitates early SLP evaluation and treatment and significantly affects oral readiness after neonatal cardiac surgery.

Safety gaps in medical team communication: Closing the loop on quality improvement efforts in the cardiac catheterization lab

Closed-loop communication (CLC) is a fundamental aspect of effective communication, critical in the cardiac catheterization laboratory (cath lab) where physician orders are verbal. Complete CLC is typically a hospital and national mandate. Deficiencies in CLC have been shown to impair quality of care. Single center observational study, CLC for physician verbal orders in the cath lab were assessed by direct observation during a 5-year quality improvement effort. Performance feedback and educational efforts were used over this time frame to improve CLC, and the effects of each intervention assessed. Responses to verbal orders were characterized as complete (all important parameters of the order repeated, the mandated response), partial, acknowledgment only, or no response. During the first observational period of 101 cases, complete CLC occurred in 195 of 515 (38%) medication orders and 136 of 235 (50%) equipment orders. Complete CLC improved over time with various educational efforts, (p < 0.001) but in the final observation period of 117 cases, complete CLC occurred in just 259 of 328 (79%) medication orders and 439 of 581 (76%) equipment orders. Incomplete CLC was associated with medication and equipment errors. CLC of physician verbal orders was used suboptimally in this medical team setting. Baseline data indicate that physicians and staff have normalized weak, unreliable communication methods. Such lapses were associated with errors in order implementation. A subsequent 5-year quality improvement program resulted in improvement but a sizable minority of unacceptable responses. This represents an opportunity to improve patient safety in cath labs.

Designing a critical care solution using in-person and telemedicine approaches in the US-Mexico border area during COVID-19

Background

UC San Diego Health System (UCSDHS) is the largest academic medical center and integrated care network in US-Mexico border area of California contiguous to the Northern Baja region of Mexico. The COVID-19 pandemic compelled several UCSDHS and local communities to create awareness around best methods to promote regional health in this economically, socially, and politically important border area.

Purpose

To improve understanding of optimal strategies to execute critical care collaborative programs between academic and community health centers facing public health emergencies during the COVID-19 pandemic, based on the experience of UCSDHS and several community hospitals (one US, two Mexican) in the US-Mexico border region.

Methods

After taking several preparatory steps, we developed a two-phase program that included 1) in-person activities to perform needs assessments, hands-on training and education, and morale building and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or educational coaching experiences.

Findings.

A clinical and educational program between academic and community border hospitals was feasible, effective, and well received.

Conclusion

We offer several policy-oriented recommendations steps for academic and community healthcare programs to build educational, collaborative partnerships to address COVID-19 and other cross-cultural, international public health emergencies.

An In-Person and Telemedicine "Hybrid" System to Improve Cross-Border Critical Care in COVID-19

Background

UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations between UCSDHS and several border community hospitals - one in the US, two in Mexico - as high volumes of severely ill patients overwhelmed hospitals.

Objective

We describe the development, implementation, feasibility, and acceptance of a novel critical care support program in three community hospitals along the US-Mexico border.

Methods

We created and instituted a hybrid critical care program involving: 1) in-person activities to perform needs assessments of equipment and supplies and hands-on training and education, and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or consultative, education-based experiences. We collected performance metrics surrounding adherence to evidence-based practices and staff perceptions of critical care delivery.

Findings

In-person intervention phase identified and filled gaps in equipment and supplies, and Tele-ICU program promoted adherence to evidence-based practices and improved staff confidence in caring for critically ill COVID-19 patients at each hospital.

Conclusion

A collaborative, hybrid critical care program across academic and community centers is feasible and effective to address cross-cultural public health emergencies.

Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle

OBJECTIVES

Daily ICU interprofessional team rounds, which incorporate the ICU Liberation ("A" for Assessment, Prevention, and Manage Pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, support both the care coordination and regular provider communication necessary for Bundle execution. This article describes evidence-based practices for conducting effective interprofessional team rounds in the ICU to improve Bundle performance.

DESIGN

Best practice synthesis.

METHODS

The authors, each extensively involved in the Society of Critical Care Medicine's ICU Liberation Campaign, reviewed the pertinent literature to identify how ICU interprofessional team rounds can be optimized to increase ICU Liberation adherence.

RESULTS

Daily ICU interprofessional team rounds that foster ICU Liberation Bundle use support both care coordination and regular provider communication within and between teams. Evidence-based best practices for conducting effective interprofessional team rounds in the ICU include the optimal structure for ICU interprofessional team rounds; the importance of conducting rounds at patients' bedside; essential participants in rounds; the inclusion of ICU patients and their families in rounds-based discussions; and incorporation of the Bundle into the Electronic Health Record. Interprofessional team rounds in the ICU ideally employ communication strategies to foster inclusive and supportive behaviors consistent with interprofessional collaboration in the ICU. Patient care discussions during interprofessional team rounds benefit from being patient-centered and goal-oriented. Documentation of ICU Liberation Bundle elements in the Electronic Health Record may help facilitate team communication and decision-making.

CONCLUSIONS

Conducting high-quality interprofessional team rounds in the ICU is a key strategy to support ICU Liberation Bundle use.

Critical Care Organizations: Building and Integrating Academic Programs

OBJECTIVE

Academic medical centers in North America are expanding their missions from the traditional triad of patient care, research, and education to include the broader issue of healthcare delivery improvement. In recent years, integrated Critical Care Organizations have developed within academic centers to better meet the challenges of this broadening mission. The goal of this article was to provide interested administrators and intensivists with the proper resources, lines of communication, and organizational approach to accomplish integration and Critical Care Organization formation effectively.

DESIGN

The Academic Critical Care Organization Building section workgroup of the taskforce established regular monthly conference calls to reach consensus on the development of a toolkit utilizing methods proven to advance the development of their own academic Critical Care Organizations. Relevant medical literature was reviewed by literature search. Materials from federal agencies and other national organizations were accessed through the Internet.

SETTING

The Society of Critical Care Medicine convened a taskforce entitled "Academic Leaders in Critical Care Medicine" on February 22, 2016 at the 45th Critical Care Congress using the expertise of successful leaders of advanced governance Critical Care Organizations in North America to develop a toolkit for advancing Critical Care Organizations.

MEASUREMENTS AND MAIN RESULTS

Key elements of an academic Critical Care Organization are outlined. The vital missions of multidisciplinary patient care, safety, and quality are linked to the research, education, and professional development missions that enhance the value of such organizations. Core features, benefits, barriers, and recommendations for integration of academic programs within Critical Care Organizations are described. Selected readings and resources to successfully implement the recommendations are provided. Communication with medical school and hospital leadership is discussed.

CONCLUSIONS

We present the rationale for critical care programs to transition to integrated Critical Care Organizations within academic medical centers and provide recommendations and resources to facilitate this transition and foster Critical Care Organization effectiveness and future success.

Implementation of an electronic checklist in the ICU: Association with improved outcomes

OBJECTIVE

To assess the impact of an electronic checklist during the morning rounds on ventilator-associated pneumonia (VAP) in the intensive care unit (ICU).

PATIENTS AND METHODS

We conducted a retrospective, before/after study in a single ICU of a university hospital. A systematic electronic checklist focusing on guidelines adherence was introduced in January 2012. From January 2008 to June 2014, we screened patients with ICU stay durations of at least 48hours. Propensity score-matched analysis with conditional logistic regression was used to compare the rate of VAP and number of days free of invasive devices before and after implementation of the electronic checklist.

RESULTS

We analysed 1711 patients (before group, n=761; after group, n=950). The rates of VAP were 21% and 11% in the before and after groups, respectively (p<0.001). In propensity-score matched analysis (n=742 in each group), VAP occurred in 151 patients (21%) during the before period compared with 72 patients (10%) during the after period (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.27-0.53). The after group showed increases in ICU-free days (OR=1.05; 95% CI=1.04-1.07) and mechanical ventilation-free days (OR=1.03; 95% CI=1.01-1.04).

CONCLUSION

In this matched before/after study, implementation of an electronic checklist was associated with positive effects on patient outcomes, especially on VAP. Further prospective studies are needed to confirm these observations.

Aligning perceptions of mistreatment among incoming medical trainees

BACKGROUND

Learner mistreatment has been a long-standing example of unprofessional behavior in medical training. Alignment of perceptions of professional behavior is a critical component of developing a defined organizational culture. Clinical vignettes addressing learner mistreatment can help to achieve this goal. Our aim was to determine whether using clinical vignettes to address learner mistreatment during onboarding can reduce variability in the perceptions of mistreatment.

MATERIALS AND METHODS

External experts in the field of labor and employment relations embedded in the clinical learning environment identified six thematic areas of potential mistreatment. Corresponding clinical case vignettes were developed and presented to incoming trainees during the onboarding process, followed by facilitated discussion. Perceptions of mistreatment before and after discussion were assessed on a Likert scale, with results compared using F-test and t-test.

RESULTS

There were 145 participants. Most participants reported previously witnessing or experiencing episodes of mistreatment before matriculation (84%), with the majority reporting multiple events. The most common offenders were faculty (57%), residents/fellows (49%), and nurses (33%). Only 10% of incoming trainees reported a previous incident of mistreatment. Postintervention scores demonstrated decreased variability (P < 0.05) in perceptions of mistreatment in all but one vignette (withholding learning opportunities). Two vignettes demonstrated higher perception of mistreatment after intervention (noneducational tasks and gender or racial discrimination, P < 0.05).

CONCLUSIONS

Mistreatment remains a prevalent phenomenon in medical training involving a wide cross-section of healthcare providers. Trainees arrive with discordant definitions of mistreatment. Alignment of individuals' definitions can be achieved through the use of carefully crafted clinical vignettes and facilitated discussion.

Application of Clinical Practice Guidelines for Pain, Agitation, and Delirium

Critically ill patients experience several severe, distressing, and often life-altering symptoms during their intensive care unit stay. A clinical practice guideline released by the American College of Critical Care Medicine provides a template for improving the care and outcomes of the critically ill through evidence-based pain, agitation, and delirium assessment, prevention, and management. Key strategies include the use of valid and reliable assessment tools, setting a desired sedation level target, a focus on light sedation, choosing appropriate sedative medications, the use of nonpharmacologic symptom management strategies, and engaging and empowering patients and their family to play an active role in their intensive care unit care.

Application of kaizen methodology to foster departmental engagement in quality improvement

The Toyota Production System, also known as Lean, is a structured approach to continuous quality improvement that has been developed over the past 50 years to transform the automotive manufacturing process. In recent years, these techniques have been successfully applied to quality and safety improvement in the medical field. One of these techniques is kaizen, which is the Japanese word for "good change." The central tenant of kaizen is the quick analysis of the small, manageable components of a problem and the rapid implementation of a solution with ongoing, real-time reassessment. Kaizen adds an additional "human element" that all stakeholders, not just management, must be involved in such change. Because of the small size of the changes involved in a kaizen event and the inherent focus on human factors and change management, a kaizen event can serve as good introduction to continuous quality improvement for a radiology department.