ArticleLiterature Review

A Systematic Review of Evidence-Informed Practices for Patient Care Rounds in the ICU

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Abstract

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.

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... By creating a framework for regular and better communication, IBR is thought to lead to improvements in team and patient outcomes. Frequently referred to as structured interprofessional bedside rounds (SIBR) or structured interdisciplinary bedside rounds (SIDR) these routines-ofcare may improve communication, patient/staff satisfaction and experience, and clinical outcomes (Gonzalo et al., 2014;Lane et al., 2013;Ratelle et al., 2018;Reeves et al., 2017b). However, the emerging literature is heterogeneous in terms of how IBR is described and where studies are published. ...
... This review builds on existing reviews in three key ways. First, by employing a scoping approach and including qualitative, quantitative, and mixed methods studies, we include a more comprehensive picture of the literature than other recent reviews have captured (Gonzalo et al., 2014;Lane et al., 2013;Pannick et al., 2015;Ratelle et al., 2018;Reeves et al., 2017b;Will et al., 2019). Second, by focusing specifically on IBR, we distinguish our efforts from those with a broader focus on interprofessional collaborative practice models in general Donovan et al., 2018;Reeves et al., 2017aReeves et al., , 2017bWeaver et al., 2014Weaver et al., , 2013. ...
... The search was performed in July 2018 and repeated in January 2019 and July 2020 to complete searching from the inception of the above databases through the end of June 2020. Unique references cited in six systematic reviews were included (Bhamidipati et al., 2016;Cypress, 2012;Gurses & Xiao, 2006;Lane et al., 2013;Ratelle et al., 2018;Walton et al., 2016). Records were de-duplicated with EndNote X9 (EndNote, n. d.) then uploaded into Rayyan (Doha, Qatar; Ouzzani et al., 2016). ...
Article
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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.
... Nurse time limitation was one of the highestranked barriers to bedside interprofessional rounding (26)(27)(28), medication administration, patient assignment load, other patient needs; new admissions were also mentioned in the literature that can be related to nursing time limitation too (23). Increased rounding time (26,29) and conflict in a daily schedule (30) are some other barriers that also remark on the necessity of staff's time consideration. ...
... Doubt about communication skills, uncertainty about the rounding, (30), feeling not being valued by MDs (26,29), lack of support from nurse managers/clinicians and senior physicians in facilitating interprofessional rounding (26) also found in literature as barriers that can be lead to reluctance nurse participation in ward rounds. ...
... Interruptions in communication (29), large team size (28), the hierarchical structure between team members (29), high turnover in team members (30), and lack of a culture of nurse-physician rounding in a ward (26,28) are barriers will make challenges against communication and collaboration in a multidisciplinary team. ...
Article
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Background & Aim: The purpose of this integrative literature review was to find, critically evaluate, and describe publications about barriers against nurse participation and collaboration in multidisciplinary ward rounds. Although multidisciplinary ward rounds are the right place for doctors and nurses to communicate, nurses’ attendance in these rounds is missed. The nurses' absence at the multidisciplinary ward rounding has apparent negative effects on the patients, their relatives, other team members, and patients’ care. Methods: A systematic approach to searching, screening, and analyzing the literature was applied. The original and review papers were used. This study was an integrative review based on Whittemore and Knafl’s framework. Web of Science, PubMed, Scopus, Cochrane, Magiran, and SID were searched by time limitation for ten years (2009-2019). The search was conducted between February 2019–March 2019. The language was limited to English and Persian. Results: After duplicate removal, title, and abstract review, 63 papers remained. After full-text control, finally, 7 papers chased for this review. Barriers for rounding were divided into 4 main categories: time limitation, reluctance to participate, ineffective communication, and infrastructure & administration. Nurse time limitation, feeling not being valued by MDs, lack of standard and structure, and nurse unawareness from time of round are the most repeated barriers. Conclusion: Barriers may need to be removed until nurse participation in multidisciplinary ward rounds improves. Some study needs to take place about this issue in Iran to identify the situation, facilitators, and barriers specific to our country. Based on them, a relevant intervention can be chased.
... (5) Daily multidisciplinary rounds (DMRs) are an approach that optimizes ICU care. (6)(7)(8) Daily multidisciplinary rounds consist of systematic patient-centered discussions aiming to establish joint therapeutic goals for the following 24 hours of ICU care. (6) Nevertheless, the best method to perform DMR analysis is still lacking. ...
... (6)(7)(8) Daily multidisciplinary rounds consist of systematic patient-centered discussions aiming to establish joint therapeutic goals for the following 24 hours of ICU care. (6) Nevertheless, the best method to perform DMR analysis is still lacking. The TELE-Critical Care versus usual Care On ICU PErformance (TELESCOPE) trial aims to evaluate whether an intervention consisting of guided DMRs supported by a remote specialist (intensivist) through telemedicine (9,10) and audit feedback on care performance will reduce ICU length of stay (LOS) compared to a control group. ...
Article
Objective: The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care. Methods: The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia. Conclusion: According to the trial's best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results.ClinicalTrials.gov registration: NCT03920501.
... 14 Therefore, using checklists may improve clinical practice and adherence to best practice guidelines. 15 Checklists can contribute to a better understanding of health care by health professionals and the consequent reduction of adverse events, such as infections related to health care, medication errors, or unplanned extubations, as well as reducing the number of invasive procedures. 16,17 Furthermore, in over 50% of cases when a PICU checklist has been used, changes have occurred to the patient's care plan. ...
... [18][19][20][21] Several studies have been conducted on checklists in PICUs. [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] From the point of view of clinical practice, the use of checklists developed in an interdisciplinary way can help professionals understand the need for safer care practices, accept and modify their behavior, 18 and improve communication between them. 27 Good professional relationships between nurses and doctors are factors that can contribute to patient safety in pediatric units. ...
Article
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Objective: This review will evaluate the effectiveness of checklists in multidisciplinary rounds compared with multidisciplinary rounds without checklists, regarding mortality and patient safety. Introduction: Single studies have demonstrated that checklists can potentially improve communication of care between health professionals, reduce adverse events, and increase adherence to best practice guidelines. However, no systematic review of the literature has explored the use of checklists in the pediatric intensive care unit. Inclusion criteria: This review will consider studies that include pediatric patients, under 18 years of age, admitted to a pediatric unit. Identified studies will compare the use of checklists in multidisciplinary rounds with multidisciplinary rounds with no checklists. The studies will also evaluate mortality and patient safety outcomes. We will consider experimental and observational studies, published in any language, with no date restrictions. Methods: The search strategy will aim to locate both published and unpublished studies. Databases to be searched include MEDLINE, the Cochrane Library, Web of Science, LILACS, Scopus, Embase, CINAHL, the Center for Reviews and Dissemination, Database of Abstracts of Reviews of Effects, and Epistemonikos. The studies will be screened and those meeting the inclusion criteria will be retained by two independent researchers. Assessment of methodology and data extraction will then be carried out. The data will be presented using a narrative synthesis and the studies will be pooled with a statistical meta-analysis, where possible. Systematic review registration number: PROSPERO CRD42021233798.
... [1][2][3][4][5] Such rounds can be nurse-driven or resident-driven. [6][7][8] Ideally, bedside rounds should be efficient, satisfy the needs of all the stakeholders, and result in optimal care plans, with the patient's family contributing to the plan. 5,9 Unfortunately, clinical teams often face challenges in accomplishing all these goals simultaneously during rounds. ...
... A literature review identified potential interventions to improve rounds and their implementation. 7,16,17 We simulated a nurse-driven, resident-driven, and a combined interprofessional rounding model before agreeing on the combined model as it promoted ownership among all members. Then we created a key driver diagram with change ideas (Fig. 1). ...
Article
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Introduction: Inconsistent workflow, communication, and role clarity generate inefficiencies during bedside rounds in a neonatal intensive care unit. These inefficiencies compromise the time needed for essential activities and result in reduced staff and family satisfaction. This study's primary aim was to reduce the mean duration of bedside rounds by 25% within 3 months by redesigning the rounding processes and applying QI principles. The secondary aims were to improve staff and family experience. Methods: We conducted this work in an academic 50-bed neonatal intensive care unit involving 350 staff members. The change interventions included: (i) reinforcing essential value-added activities like standardizing rounding time, the sequencing of patients rounded, sequencing each team member rounding presentations, team preparation, bedside presentation content, and time management; (ii) reducing non-value-added activities; and (iii) moving value-added nonessential activities outside of the rounds. Results: The mean duration of rounds decreased from 229 minutes in the pre-implementation to 132 minutes in the postimplementation phase. The proportion of staff showing satisfaction regarding various components of the rounds increased from 5% to 60%, and perceived staff involvement during the rounds increased from 70% to 77%. Ninety-three percent of family experience survey respondents expressed satisfaction at being invited for bedside reporting and being involved in decision-making or care planning. The staff did not report any adverse events related to the new rounds process. Conclusion: Redesigning bedside rounds improved staff engagement and workflow, resulting in efficient rounds and better staff experience.
... However, there are hardly any standards or guidelines as to how ICU rounds should be structured and performed. In 2013 Lane et al. [4] published a first systematic review that provided 13 best practices for ICU rounds. In a 2015 published survey conducted using 111 Canadian ICUs, Holodinsky et al. [5] described considerable variations in rounding practices and several opportunities for improvement. ...
... A standardized survey was developed considering the few aforementioned studies that exist on this topic [4,5]. Besides those, no other guidelines or references on ICU rounding could be found. ...
Article
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Objective To gather data about structural and procedural characteristics of patient rounds in the intensive care unit (ICU) setting. Design A structured online survey was offered to members of two German intensive care medicine societies. Measurements and main results Intensivists representing 390 German ICUs participated in this study (university hospitals 25%, tertiary hospitals 23%, secondary hospitals 36%, primary hospitals 16%). In 90% of participating ICUs, rounds were reported to take place in the morning and cover an average of 12 intensive care beds and 6 intermediate care beds within 60 min. With an estimated bed occupancy of 80%, this averaged to 4.3 min spent per patient during rounds. In 96% of ICUs, rounds were stated to include a bedside visit. On weekdays, 86% of the respondents reported holding a second ICU round with the attendance of a qualified decision-maker (e.g. board-certified intensivist). On weekends, 79% of the ICUs performed at least one round with a decision-maker per day. In 18%, only one ICU round per weekend was reported, mostly on Sundays. The highest-qualified decision-maker present during rounds on most ICUs was an ICU attending (57%). Residents (96%) and intensive care nurses (87%) were stated to be always or usually present during rounds. In contrast, physiotherapists, respiratory therapists or medical specialists such as pharmacists or microbiologist were not regular members of the rounding team on most ICUs. In the majority of cases, the participants reported examining the medical chart directly before or during the bedside visit (84%). An electronic patient data management system (PDMS) was available on 31% of ICUs. Daily goals were always (55%) or usually (39%) set during rounds. Conclusion This survey gives a broad overview of the structure and processes of ICU rounds in different sized hospitals in Germany. Compared to other mostly Anglo-American studies, German ICU rounds appear to be shorter and less interdisciplinary.
... The role of the clinical librarian is especially important in critical care where patients are often admitted with life-threatening conditions and health professionals are required to make clinical decisions at speed (Hansen & Severinsson, 2009;Johnson et al., 2010;Lane et al., 2013;Rose, 2011). Being admitted to critical care, or having a family member admitted, is often an emotionally distressing experience, which can sometimes be made worse by insufficient information about the condition or treatment. ...
... Being admitted to critical care, or having a family member admitted, is often an emotionally distressing experience, which can sometimes be made worse by insufficient information about the condition or treatment. Patients and families have identified the importance of appropriate and accurate evidence-based information as a key factor in improving their experience in critical care (Auerbach et al., 2005;Khalaila, 2013;Sherlock et al., 2009;Stricker et al., 2009). ...
Article
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Background Timely information provided by clinical librarians can contribute to outcomes such as improved patient care and time savings for hospital staff. What is unknown is the return on investment (ROI) of a clinical librarian on a critical care unit. Objective The aim of this study was to assess the ROI, from the employer perspective, of placing a clinical librarian in a critical care unit in a large UK acute hospital. Methods Using a mixed methods approach, ROI was estimated by comparing the total costs with the total monetised benefits of implementing the clinical librarian intervention. Total costs included salary and equipment costs. Total monetised benefits included time saving for hospital staff, support for professional development and improved patient care. Results When total monetised benefits were compared with total costs, the 15‐month clinical librarian intervention generated a positive ROI of £1.18–£3.03 for every £1 invested. Discussion Using outcome measures derived from previous research, this novel study generated promising results indicative for commissioners seeking to improve patient care and deliver value for money. To improve generalisability, multisite studies using standardised ROI tools are recommended. Conclusion Employing a clinical librarian in a critical care unit can generate a positive ROI.
... 4 A checklist can be used in several ways in clinical practice, including for decision-making in care, such as during bedside rounds. 10 It can also be used as a tool to facilitate teaching and learning and evaluate the performance of nursing and medical residents, as well as to empower nurses and young physicians during discussions with more experienced professionals. 2 The application of checklists in the PICU has been described in the literature 7,8,[11][12][13][14][15][16] ; however, we did not find any published reports of the development or implementation of these checklists in Brazil. Despite the availability of tools that could be translated and adapted to our situation, we chose to build a new checklist based on our knowledge of the professional practice environment in which the instrument would be used. ...
Article
Background The use of checklists in the pediatric intensive care unit can help improve the quality of care and patient safety. Objectives To build and validate a checklist for use in interprofessional rounds in a pediatric intensive care unit. Methods This methodological study was conducted in a 20-bed pediatric intensive care unit serving children up to 14 years old. A checklist prototype was constructed through review of the literature and achievement of consensus among the professionals providing care in the unit. Content validation was performed using a modified Delphi technique involving specialists with more than 5 years of experience in pediatric intensive care, methodological studies, and patient safety. Content validity ratios were calculated for the elements of the checklist, which were considered valid when they reached values greater than 0.78. The checklist was tested for usability, application time, and effects on patient care, and feedback was obtained from potential users. Results Before content validation, the checklist contained 11 domains, 32 items, and 6 daily goals. The invitation to validate content was sent to 86 specialists, and content validity was achieved after 2 rounds of evaluation, with the checklist elements having content validity ratios ranging from 0.94 to 0.97. The mean application time of the checklist was 5 minutes. The final version consisted of 11 domains, 33 items, and 8 daily goals. Conclusions This study resulted in a useful and valid instrument for application in interprofessional rounds that was tailored to the needs of local health care professionals.
... As a result of work hours restrictions and increasing demands for trainee's time, learning to work efficiently in the medical system has become an important goal for resident education along with traditional topics such as medical knowledge and communication skills [7,8]. However, many interventions aimed at improving rounding efficiency have focused on reducing time spent on external factors -such as developing structured rounding tools for data gathering, standardizing the electronic medical record (EMR), regionalizing patients, and reducing time-wasting interruptions on rounds -without addressing trainee and attending behaviors during rounds [9][10][11][12]. Of note, one study that evaluated the impact of standardizing attending rounds' structure found that despite reducing rounding length by 8 min, trainees reported decreased satisfaction with rounds and perceived them as lasting 15 min longer [13]. ...
Article
Full-text available
Background Rounds are a foundational practice in patient care and education in the inpatient healthcare environment, but increased demands on inpatient teams have led to dissatisfaction with inefficient, ineffective rounds. In this study, we describe the design, implementation, and evaluation of a novel rounding framework (“NET Rounding”) that provides behaviorally-based strategies to inpatient teams to achieve efficient rounds while preserving patient safety and education. Methods NET Rounding consists of nine recommendations divided into three categories: N ovel rounding strategies, shared E xpectations, and T ime management. This framework was introduced as a bundled intervention at a single-site, quaternary-care, academic hospital from March–May 2021. Eighty-three residents and 64 attendings rotated on the inpatient teaching service during the intervention period. Participants were surveyed before, during, and after their rotation about rounding’s contribution to educational value, patient safety, resident duty hour violations and rotation experience. Additionally, rounding duration was recorded daily by team attendings. Results Thirty-two residents (38.5%) and 45 attendings (70%) completed post-intervention surveys. Rounding duration was recorded on 529/626 rounding days (80.6%) and resulted in achieving efficient rounds on 412/529 days (77.9%). Residents reported improvement in perceived patient safety (54 to 84%, p = 0.0131) and educational value of rounds (38 to 69%, p = 0.0213) due to NET Rounding; no change was observed amongst attendings in these areas (79 to 84% and 70 to 80%, p = 0.7083 and 0.4237, respectively). Overall, 29/32 residents (91%) and 33/45 attendings (73%) reported a positive impact on rotation experience. Conclusions NET Rounding enabled inpatient teaching teams to complete rounds more efficiently while preserving patient safety and education.
... In addition to the benefits provided at a unit level, implementing a standardized tool also improved nurses' ease and comfort with reporting patients utilizing the new reporting tool. This finding is consistent with a systematic review conducted by Lane and colleagues [11] which states that best practice on morning rounds should include standardization of time, location, use of check-list, and discussion of patient goals. A major strength of the quality improvement initiative is the change in structure of morning rounds which is focused on safety through collaboration with an IPT and leadership to promote optimal clinical outcomes. ...
Article
Structured morning rounds have been used to improve communication, provide learning opportunities, and support patient care in various healthcare settings. The leadership team in an inner-city Inpatient Mental Health Unit identified a gap in the structure of morning rounds; to remedy this, a standardized reporting tool and structured morning rounding process were implemented. This short communication reports on an evaluation of staff’s perceptions on the outcomes of using a standardized reporting tool and structured rounding process to improve efficiency and communication regarding patient care among an interprofessional team. Feedback was provided on logistics, attendance, supporting factors that ensured ease of use for the new structure, and benefits of the program. While this evaluation focuses on the opinions of nurses, it serves as an example for leadership in various healthcare units on the benefits of a structured rounding program, and key factors that contribute to making the process successful. This short communication also provides an example for an efficient communication tool that can be adapted to meet the needs of various groups of healthcare disciplines.
... Critically ill individuals have an exceedingly poor clinical state; endure life-threatening complications, trauma, and stress; and have a high metabolic rate for extended periods of time; as a result, their physical function and immunity may swiftly diminish [2]. Meanwhile, as a result of the disease's impacts, many patients may develop swallowing difficulties and become unable to eat; the nutritional condition of critically sick patients is generally poor [3]. Early enteral nutrition assistance is essential to enhance patients' nutritional status. ...
Article
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Objective: The purpose of this research was to rigorously assess the impact of early low-fever enteral feeding supplementation in critically sick patients. Methods: PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Physiotherapy Evidence Database were searched for randomized controlled trials related to enteral nutrition support of critically ill patients (retrieval time was limited to June 30, 2021); data were extracted after screening the literature, and the quality of meta-analysis was evaluated. Results: When compared to adequate caloric enteral nutrition support, early low caloric enteral nutrition support reduces the incidence of intolerance to nutrition support (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13) and the insulin dose during enteral nutrition support (MD = -17.21, 95 percent CI: -19.91 to -14.51, P = 0.00001). However, it had no effect on intensive care unit (ICU) treatment duration (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13), in-hospital mortality (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13), or infection incidence (OR = 1.00, 95 percent CI: 0.85, 1.19, P = 0.98). Conclusion: When compared to sufficient caloric enteral nutrition support, early low-calorie enteral nutrition support lowers the risk of severe illness. The rate of intolerance to nutritional assistance and the decrease in insulin dosage supplied had no effect on the length of ICU therapy, patient death, or infection incidence.
... Critical care is always facing complex, life-threatening conditions and needs to make rapid decision on account of incomplete data. Patient care rounds in the ICU include discussions based on reviewing clinical data and concluding care plans (3). Rounds are a crucial portion in daily clinical schedule in ICU. ...
Article
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Point-of-care ultrasonography (POCUS) is performed by a treating clinician at the patient's bedside, provides a acquisition, interpretation, and immediate clinical integration based on ultrasonographic imaging. The use of POCUS is not limited to one specialty, protocol, or organ system. POCUS provides the treating clinician with real-time diagnostic and monitoring information. Visual rounds based on multiorgan POCUS act as an initiative to improve clinical practice in the Intensive Care Unit and are urgently needed as part of routine clinical practice.
... useful in intensive care units (ICUs) [5,9]. MDR typically include physicians and bedside registered nurses (RNs), as well as respiratory therapists, pharmacists, case managers, child life specialists, ethicists, and patients' families [10]. ...
Article
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Standardized rounding checklists during multidisciplinary rounds (MDR) can reduce medical errors and decrease length of pediatric intensive care unit (PICU) and hospital stay. We added a standardized process for MDR in our oncologic PICU. Our study was a quality improvement initiative, utilizing a four-stage Plan–Do–Study–Act (PDSA) model to standardize MDR in our PICU over 3 months, from January 2020 to March 2020. We distributed surveys to PICU RNs to assess their understanding regarding communication during MDR. We created a standardized rounding checklist that addressed key elements during MDR. Safety event reports before and after implementation of our initiative were retrospectively reviewed to assess our initiative’s impact on safety events. Our intervention increased standardization of PICU MDR from 0% to 70% over three months, from January 2020 to March 2020. We sustained a rate of zero for CLABSI, CAUTI, and VAP during the 12-month period prior to, during, and post-intervention. Implementation of a standardized rounding checklist may improve closed-loop communication amongst the healthcare team, facilitate dialogue between patients’ families and the healthcare team, and reduce safety events. Additional staffing for resource RNs, who assist with high acuity patients, has also facilitated bedside RN participation in MDR, without interruptions in clinical care.
... 7,8 However, many interventions aimed at improving rounding e ciency have focused on reducing time spent on external factors -such as developing structured rounding tools for data gathering, standardizing the electronic medical record (EMR), regionalizing patients, and reducing time-wasting interruptions on rounds -without addressing trainee and attending behaviors during rounds. [9][10][11][12] Of note, one study that evaluated the impact of standardizing attending rounds' structure found that despite reducing rounding length by eight minutes, trainees reported decreased satisfaction with rounds and perceived them as lasting fteen minutes longer. 13 Taken together, these studies demonstrate that simply focusing on reducing time spent rounding is not enough to improve the rounding experience even when e ciency is improved; emphasis must be placed on educational and patient care goals of the inpatient teams as well. ...
Preprint
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Background: Rounds are a foundational practice in patient care and education in the inpatient healthcare environment, but increased demands on inpatient teams have led to dissatisfaction with inefficient, ineffective rounds. In this study, we describe the design, implementation, and evaluation of a novel rounding framework (“NET Rounding”) that provides behaviorally-based strategies to inpatient teams to achieve efficient rounds while preserving patient safety and education. Methods: NET Rounding consists of nine recommendations divided into three categories: Novel rounding strategies, shared Expectations, and Time management. This framework was introduced as a bundled intervention at a single-site, quaternary-care, academic hospital from March-May 2021. 83 residents and 64 attendings rotated on the inpatient teaching service during the intervention period. Participants were surveyed before, during, and after their rotation about rounding’s contribution to educational value, patient safety, resident duty hour violations and rotation experience. Additionally, rounding duration was recorded daily by team attendings. Results: 32 residents (38.5%) and 45 attendings (79%) completed post-intervention surveys. Rounding duration was recorded on 529/626 rounding days (80.6%) and resulted in achieving efficient rounds on 412/529 days (77.9%). Residents reported improvement in perceived patient safety (54% to 84%, p=0.0131) and educational value of rounds (38% to 69%, p=0.0213) due to NET Rounding; no change was observed amongst attendings in these areas (79% to 84% and 70% to 80%, p=0.7083 and 0.4237, respectively). Overall, 29/32 residents (91%) and 33/45 attendings (73%) reported a positive impact on rotation experience. Conclusions: NET Rounding enabled inpatient teaching teams to complete rounds more efficiently while preserving patient safety and education.
... Higher scores indicate greater satisfaction, more frequent frightening experiences, greater recall, and greater awareness of surroundings. 7 ...
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Aims: to describe the experiences of Jordanian patients during their stay in intensive care unit (ICU) and to explore associated factors. Background: Various factors can negatively affect patients' experiences and lead to negative consequences that can affect their outcomes. Materials & Methods: A descriptive, correlational design was used to collect data from 150 patients using the Intensive Care Experience Questionnaire through structured interviews after being transferred from medical and surgical ICUs to general wards. Results: The results showed that the longer the length of ICU stay (LOS) (>7 days) the higher frightening experience (r = 0.2, p < 0.05), the lower awareness of surrounding (r = −0.28, p < 0.01), and the lower satisfaction with care (r = −0.22, p < 0.01). The results showed a negative correlation between receiving sedation and awareness of surroundings (r = −0.33, p < 0.01), and recall of ICU experiences (r = −0.23, p < 0.01), and a positive correlation with frightening experiences (r = 0.2, p < 0.05). Conclusion: Health care activities, clinical and socio-demographic factors can affect the psychological experiences of patients in the ICU. Longer ICU stay is associated with more negative experiences. Relevance to clinical practice Negative ICU experience leads to poor outcomes and longer ICU stays contribute to such negative experiences. Improving nurses' awareness of patients' experiences during ICU stay would improve nurses' care behaviors, reduce unintended negative experiences.
... 15 16 However, full implementation of DMR is still challenging, since DMR must contain several attributes in order to maximise its results: its multidisciplinary character; proper settings; time and team standardisations; definition of roles; use of guiding tools; reduction of interruptions and focus on documented objectives. 14 Telecommunication use for healthcare practice, the prototype for what telemedicine has become, has been described since the advent of telecommunication. 17 The availability of high-speed data traffic has expanded the boundaries of Telemedicine, allowing the emergence of the first trial with critically ill patients in 1977. ...
Article
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Introduction: Daily multidisciplinary rounds (DMRs) consist of systematic patient-centred discussions aiming to establish joint therapeutic goals for the next 24 hours of intensive care unit (ICU) care. The aim of the present study protocol is to evaluate whether an intervention consisting of guided DMRs, supported by a remote specialist and audit/feedback on care performance will reduce ICU length of stay compared with a control group. Methods and analysis: A multicentre, controlled, cluster-randomised superiority trial including 30 ICUs in Brazil (15 intervention and 15 control), from August 2019 to June 2021. In a parallel assignment, ICUs are randomised to a complex-intervention composed by daily rounds carried out through Tele-ICU by a remote ICU physician; development of local quality indicators dashboards coupled with monthly meetings with local leadership; and dissemination of evidence-based clinical protocols versus usual care. Primary outcome is ICU length of stay. Secondary outcomes include classification of the unit according to the profiles defined by the standardised resource use and the standardised mortality rate, hospital mortality, incidence of healthcare-associated infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation or alert and calm, rate of patients under normoxaemia. All adult patients admitted after the beginning of the study in each participant ICU will be enrolled. Inclusion criteria (clusters): public Brazilian ICUs with a minimum of 8 ICU beds interested/committed to participating in the study. Exclusion criteria (clusters): units with fully established DMRs by an intensivist, specialised or step-down units. Ethics and dissemination: The study protocol was approved by the institutional review board (IRB) of the coordinator centre, and by IRBs of each enrolled hospital/ICU. Statistical analysis protocol is being prepared for submission before the end of patient's enrolment. Results will be disseminated through conferences, peer-reviewed journals and to each participating unit. Trial registration number: NCT03920501; Pre-results.
... Many EBPs in the ICU are meant to guide the complex workflow of the critical care team. These include structured multidisciplinary rounds [4][5][6][7], the use of protocols to facilitate weaning from mechanical ventilation [8][9][10], and the adoption of structured handoff protocols for patient transfer from the operating room (OR) to the ICU [11][12][13][14]. When employed, these EBPs improve patient outcomes through, for example, the prevention of medical errors and adverse events [15,16]. ...
Article
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Background The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings. Methods The Handoffs and Transitions in Critical Care—Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU). Discussion The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings. Trial registration ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020.
... Although interprofessional rounds improve information transmission and communication among care providers in acute care, prior studies have shown chances are high for incomplete information transmission and errors during these rounds (Kochendorfer et al., 2010). In particular, during interprofessional rounds, care providers primarily use either professionspecific terms or unstructured discussions for verbal communication; both can result in information loss and misinterpretation (Collins et al., 2010;Lane et al., 2013). ...
Article
The lack of a proper system for ongoing open interprofessional communication among care providers increases miscommunications and medical errors. Seamless access to patient information is important for care providers to prevent miscommunication and improve patient safety. A shared understanding of the information needs of different care providers in an interprofessional team is lacking. Our purpose is to identify care providers’ information needs from the perspective of different professions for communication, shared understanding about the patient, and decision-making. We conducted semi-structured interviews with 10 subject matter experts representing eight professions, including dentistry, dietetics, medicine, nursing, occupational therapy, pharmacy, physical therapy, and social work in a 465-bed academic hospital at a large urban Midwestern city. We used an in-house rounding tool presenting physicians’ information needs and a hypothetical patient scenario to collect participants’ feedback. Interview notes were coded using direct content analysis. We identified 22 additional essential data elements for an interprofessional rounding tool. We categorized those into six domains: discharge-related, social determinants of health, hospital safety, nutrition, interprofessional situation awareness, and patient history. A well-designed validated rounding tool that includes an interprofessional team of care providers’ information needs could improve communication, care planning, and decision-making among them.
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This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
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This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
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This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
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This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
Chapter
This book is one of the first to comprehensively summarise the latest thinking and research in the rapidly evolving field of quality management in intensive care. Quality indicators and outcome measures are discussed with a practical focus on patient-centred, evidence-based implementation for safer and more effective clinical practice. Chapters on topics such as teambuilding, patient satisfaction, mortality and morbidity, and electronic management systems are organised into three sections, covering quality management at the scale of the individual patient, the intensive care unit, and the national and international level. Written by a team of over forty international experts in the specialty, with editors who have been heavily involved for many years with the European Society of Intensive Care Medicine, the book reflects commonly accepted goals and guidelines for best practice, and will be valuable for practitioners worldwide. The ideal one-stop resource for intensive care physicians as well as ICU and hospital managers.
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Widespread use of telehealth, mobile health, and remote patient monitoring during the COVID-19 pandemic has given users a vision of what is possible in future healthcare worldwide. Artificial intelligence and predictive modeling capitalize on in-time, continuous data collection, and analytics to support patient and clinician decision-making. The necessary shift in health technology adoption during the pandemic has also highlighted a shift toward digital, health, and cultural literacy and the need for clinician and institutional competencies in order to maximize technology adoption and improve health outcomes. Healthcare providers and entire systems must consider necessary adjustments to financing, reimbursement, policy, training, and infrastructure. Propelled by the needs caused by the pandemic, there exists an opportunity to build on lessons learned and to create a new vision for the future of healthcare. Research is needed in the areas of user-centered design, implementation and effectiveness approach, models of care, human–computer interaction, ethical and legal issues, and economic cost analyses.
Article
Background Multidisciplinary rounds (MDRs) are scheduled, patient-focused communication mechanisms among multidisciplinary providers in the intensive care unit (ICU). Objective i-Dashboard is a custom-developed visualization dashboard that supports (1) key information retrieval and reorganization, (2) time-series data, and (3) display on large touch screens during MDRs. This study aimed to evaluate the performance, including the efficiency of prerounding data gathering, communication accuracy, and information exchange, and clinical satisfaction of integrating i-Dashboard as a platform to facilitate MDRs. Methods A cluster-randomized controlled trial was performed in 2 surgical ICUs at a university hospital. Study participants included all multidisciplinary care team members. The performance and clinical satisfaction of i-Dashboard during MDRs were compared with those of the established electronic medical record (EMR) through direct observation and questionnaire surveys. Results Between April 26 and July 18, 2021, a total of 78 and 91 MDRs were performed with the established EMR and i-Dashboard, respectively. For prerounding data gathering, the median time was 10.4 (IQR 9.1-11.8) and 4.6 (IQR 3.5-5.8) minutes using the established EMR and i-Dashboard (P<.001), respectively. During MDRs, data misrepresentations were significantly less frequent with i-Dashboard (median 0, IQR 0-0) than with the established EMR (4, IQR 3-5; P<.001). Further, effective recommendations were significantly more frequent with i-Dashboard than with the established EMR (P<.001). The questionnaire results revealed that participants favored using i-Dashboard in association with the enhancement of care plan development and team participation during MDRs. Conclusions i-Dashboard increases efficiency in data gathering. Displaying i-Dashboard on large touch screens in MDRs may enhance communication accuracy, information exchange, and clinical satisfaction. The design concepts of i-Dashboard may help develop visualization dashboards that are more applicable for ICU MDRs. Trial Registration ClinicalTrials.gov NCT04845698; https://clinicaltrials.gov/ct2/show/NCT04845698
Article
Objectives: Design, implement, and evaluate a rounding checklist with deeply embedded, dynamic electronic health record integration. Design: Before-after quality-improvement study. Setting: Quaternary PICU in an academic, free-standing children's hospital. Patients: All patients in the PICU during daily morning rounds. Interventions: Implementation of an updated dynamic checklist (eSIMPLER) providing clinical decision support prompts with display of relevant data automatically pulled from the electronic health record. Measurements and main results: The prior daily rounding checklist, eSIMPLE, was implemented for 49,709 patient-days (7,779 patients) between October 30, 2011, and October 7, 2018. eSIMPLER was implemented for 5,306 patient-days (971 patients) over 6 months. Checklist completion rates were similar (eSIMPLE: 95% [95% CI, 88-98%] vs eSIMPLER: 98% [95% CI, 92-100%] of patient-days; p = 0.40). eSIMPLER required less time per patient (28 ± 1 vs 47 ± 24 s; p < 0.001). Users reported improved satisfaction with eSIMPLER (p = 0.009). Several checklist-driven process measures-discordance between electronic health record orders for stress ulcer prophylaxis and user-recorded indication for stress ulcer prophylaxis, rate of venous thromboembolism prophylaxis prescribing, and recognition of reduced renal function-improved during the eSIMPLER phase. Conclusions: eSIMPLER, a dynamic, electronic health record-informed checklist, required less time to complete and improved certain care processes compared with a prior, static checklist with limited electronic health record data. By focusing on the "Five Rights" of clinical decision support, we created a well-accepted clinical decision support tool that was integrated efficiently into daily rounds. Generalizability of eSIMPLER's effectiveness and its impact on patient outcomes need to be examined.
Article
Communication errors are the leading root cause of preventable adverse events in hospitals. Patient care rounds provide the most important opportunity for interprofessional communication; however, rounds involve many interprofessional team members, and it can be challenging to achieve optimal communication and team functioning. While rounding best practices have been identified, implementations of best practices have produced mixed results, and little emphasis has been placed on explicitly aligning interventions to user needs. The goal of this study was to elucidate health care providers’ (HCPs) rounding needs and to align intervention design to those needs to improve interprofessional communication within a paediatric critical care unit (CCU). Interview and survey data were collected to identify needs and a participatory design approach was taken to transform needs into intervention(s). The main needs identified led to specific changes included in the intervention design such as changes in the structure, content and timing of morning rounds.
Background Improving care of critically ill patients requires using an interprofessional care model and care standardisation. Objectives Determine whether collaborative patient care rounds in the intensive care unit increases practice consistency with respect to common considerations such as delirium prevention, device use, and indicated prophylaxis, among others. Secondary objective to assess whether collaborative interprofessional format improved nursing perceptions of collaboration. Methods Single centre, pre- and post- intervention design. collaborative patient care rounding format implemented in three intensive care units in an academic tertiary care centre. format consisted of scripted nursing presentation, provider checklist of additional practice considerations, and daily priority goals documentation. measurements included nursing participation, consideration of selected practice items, daily goal verbalisation, and nursing perception of collaboration. Results Pre- and post-intervention measurements indicate gains in consideration of eight of thirteen bundle items (p < 0.05), with the greatest gains seen in nurse-presented items. Increases were observed in verbalisation of daily goals (59.8% versus 89.1%, p < 0.0001), nurse participation (83.9% versus 91.8%, p = 0.056), and nurse collaboration ratings (p < 0.0001). Conclusion This study describes implementation of collaborative patient care rounds with corresponding increases in consideration of selected practice items, verbalisation of daily goals, and perceptions of collaboration.
Article
Rationale, Aims and Objectives Guidelines recommend inviting family members of intensive care unit (ICU) patients to rounds. We aimed to create a toolkit to support family participation in ICU bedside rounds, based upon evidence from research and in collaboration with ICU family member representatives and healthcare providers. Methods Ethnographic observations of rounds and interviews and focus groups with family members and ICU healthcare providers were analyzed for key themes, barriers and facilitators of participation, and suggestions. A full day workshop with family representatives and providers (physicians, nurses, social workers, and unit managers) from a diverse range of adult ICUs in Western Canada, including several community ICUs and a majority of large, urban ICUs enabled the collaborative development of key toolkit elements. Results We have developed an evidence‐informed approach to patient‐and‐family‐centered rounds that highlights the importance of six key elements foundational to patient and family centered rounds: Invitation, Orientation, Engagement, Summary, Questions, and Communication Follow‐Up. We describe strategies, techniques, and templates to optimize these elements and interactions so that communication is more meaningful, and to facilitate the ability of family members to adopt a meaningful role as contributing members of the care team. Conclusion There is consensus on general strategies for facilitating family participation in rounds and meaningful communication between family and the healthcare team during rounds as an important element of the continuum of communication in the ICU. The incorporation of these elements should be standardized, though tailored to user needs.
Article
Full-text available
Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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Context Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear.Objective To evaluate the association between ICU physician staffing and patient outcomes.Data Sources We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non–English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001).Study Selection We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU.Data Synthesis We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment.Conclusions High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS. Figures in this Article Approximately 1% of the US gross domestic product is consumed in the care of intensive care unit (ICU) patients.1 Despite this considerable investment of resources, there is wide variation in ICU organization,2- 3 and studies have suggested that differences in ICU organization may affect patient outcome. For example, staffing ICUs with critical care physicians (intensivists) may improve clinical outcomes.4 A conceptual model that explains this finding is that physicians who have the skills to treat critically ill patients and who are immediately available to detect and treat problems may prevent or attenuate morbidity and mortality.2 Staffing ICUs with intensivists may also decrease resource use because these physicians may be better at reducing inappropriate ICU admissions, preventing complications that prolong length of stay (LOS), and recognizing opportunities for prompt discharge.2 Intensive care unit staffing is typical of an organizational issue in health care in that, despite its potential importance in clinical and economic outcomes, it is not studied by using randomized trials. For example, the widely held belief that outcomes are better after surgery performed by experienced surgeons or hospitals is based solely on observational data.5 Practical and ethical reasons exist to explain why such organizational characteristics are not subjected to randomized trials. Yet, as changes occur in the way health care is organized, financed, and delivered, it will be important to understand the impact of organizational characteristics, such as ICU physician and nurse staffing, on patient outcomes through systematic reviews.6 To inform health policy, we will need to synthesize evidence that is predominantly observational. Accordingly, the goal of this systematic review was to examine the effect of ICU physician staffing on hospital and ICU mortality and LOS.
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The objective was to assess the impact of new guidance on the conduct of narrative synthesis in systematic reviews of effectiveness, by means of a blinded comparison of guidance-led narrative synthesis against a meta-analysis of the same study data.The conclusions of the two syntheses were broadly similar. However, differences between the approaches meant that conclusions about the impact of moderators of effect appeared stronger when derived from the meta-analysis, whereas implications for future research appeared more extensive when derived from the narrative synthesis. These findings emphasize that a rigorously conducted narrative synthesis can add meaning and value to the findings of meta-analysis.The guidance framework provided a useful vehicle for structuring a narrative synthesis and increasing transparency and rigour of the process.While there may be risks with overinterpretation of study data, the framework, tools and techniques described in the guidance appear to increase the transparency and reproducibility of narrative synthesis.
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Checklists may reduce errors of omission for critically ill patients. To determine whether prompting to use a checklist improves process of care and clinical outcomes. We conducted a cohort study in the medical intensive care unit (MICU) of a tertiary care university hospital. Patients admitted to either of two independent MICU teams were included. Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting. One hundred and forty prompted group patients were compared with 125 control and 1,283 preintervention patients. Compared with control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of deep vein thrombosis and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13-0.96; P = 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P = 0.014), which remained significant after risk adjustment (odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P = 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P = 0.02). Checklist availability alone did not improve mortality or length of stay compared with preintervention patients. In this single-site, preliminary study, checklist-based prompting improved multiple processes of care, and may have improved mortality and length of stay, compared with a stand-alone checklist. The manner in which checklists are implemented is of great consequence in the care of critically ill patients.
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Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR. Descriptive correlational study of common goals verbally stated during daily ICU interdisciplinary rounds compared with the presence of those goals, and actions related to those goals, documented in the EHR over the subsequent 24 h for 28 patients over 15 days. The study setting was a neurovascular ICU with a fully implemented electronic nursing and physician documentation system. Descriptive statistics and χ(2) analyses were used to assess differences in EHR documentation of stated goals and goal-related actions. Inter-coder reliability was performed on 16 (13%) of the 127 stated goals. One-quarter of the stated goals were not documented in the EHR. If a goal was not documented, actions related to that goal were 60% less likely to be documented. The attending physician note contained 81% of the stated ventilator weaning goals, but only 49% of the sedation weaning goals; additionally, sedation goals were not part of the structured nursing documentation. Inter-coder reliability (κ) was greater than 0.82. Observations in a single ICU setting at a large academic medical center using a commercial EHR. The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.
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Expounds on the relatively new technique of meta-synthesis which is methodologically under developed and under theorised in the health research literature. One of a handful of international papers in nursing and midwifery in this field. Invited to speak at international meeting for Cochrane Qualitative Research Collaboration Group
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Clinical handover is a necessary process for the continuation of safe patient care; however, deficiencies in the handover process can introduce error. While the number of handover studies increases, few have validated implemented improvements with repeated audit. To improve the morning handover round on a busy critical care unit and assess sustainability of improvement through repeated audit. A quality improvement process based on prospective observational assessment of the doctor's shift-change handover was carried out, assessing the content of clinical information and effects of distractions, location and timing. The effect of a training session for the junior doctors with the introduction of a standardised handover protocol was assessed. The content of clinical information improved after the training session with introduction of a standardised protocol, but returned to baseline with a new cohort of untrained doctors. Distractions were associated with increased handover times for individual patients and for total handover time. Overall, handover time was shortest in the coffee room compared with ward and lecture theatre handovers. Individual patient handover time was positively correlated with clinical content scores. Four indices of critical illness all positively correlated with increased handover time. Early specific training is vital for quality clinical handover. Distractions during handover cause inefficiency and can adversely affect information transfer. Changing handover location according to local environment can yield improved efficiency, structure and ease of management. Adequate time must be allocated for clinical handover especially when dealing with very sick and complex patients.
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In the context of systematic reviews, statistical meta-analysis of findings is not always possible. Where this is the case, or where a review of implementation evidence is required, narrative synthesis of data is typically undertaken. Drawing on recently developed guidance aimed at those undertaking data synthesis – and information on the implementation of domestic smoke detectors – we present findings from a demonstration of the tools and techniques that can be used in a narrative synthesis. The work demonstrates how this process can be made more transparent, and suggests that using the tools and techniques can improve the quality of narrative synthesis. French Dans le contexte de revues systématiques, une méta-analyse des conclusions n'est pas toujours possible. Lorsque c'est le cas, ou lorsqu'une revue de la mise en œuvre est nécessaire, on fait généralement une synthèse narrative des données. Sur la base de directives récemment élaborées ciblant les personnes qui entreprennent la synthèse des données – et l'information sur la mise en œuvre des détecteurs de fumée – nous présentons les conclusions d'une démonstration des outils et des techniques qui peuvent être utilisés dans une synthèse narrative. Le travail démontre comment on peut rendre ce processus plus transparent, et suggère que l'utilisation des outils et des techniques peut améliorer la qualité de la synthèse narrative. Spanish En el contexto de análisis sistemático, los meta análisis estadísticos de resultados no son siempre posibles. Ya sea este el caso o si se requiere un análisis de evidencia de implementación, la síntesis de datos es típicamente emprendida. Basándonos en una guía desarrollada recientemente apuntada a la síntesis de datos emprendida - y en la información de la implementación de los detectores de humo domésticos- presentamos resultados de una demostración de las herramientas y técnicas que se pueden usar en una síntesis narrativa. El trabajo demuestra cómo este proceso se puede hacer más transparente y sugiere que usando las herramientas y técnicas se puede mejorar la calidad de la síntesis narrativa.
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Critically ill patients are medically complex and may benefit from a multidisciplinary approach to care. 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. 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. 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.
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David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
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The aim of this study was to explore differences in the verbal content of handovers and rounds conducted in uni- and interdisciplinary social contexts. We expected higher proportions of goals to be articulated during interdisciplinary rounds. Lack of explanatory connections between round improvement initiatives and outcomes suggest insufficient understanding about health care communications, especially the role of social interaction. The recognition-primed abstract decomposition space (RP-ADS) was used to analyze the information content of nurse handovers and morning rounds in a unidisciplinary- (physicians only) and an interdisciplinary-round intensive care unit (ICU). Data were collected using audio recordings of rounds and handovers for five patients for 5 days each in both ICUs. Hierarchical log-linear analyses show strong associations between events (medical rounds vs. nurses' shift handovers), type (uni- vs. interdisciplinary), and focus (levels of the RP-ADS) with highly significant combined two-way and higher-order interactions, LRchi2(df=4) = 30.91, p < .0001. All tests of partial association were also highly significant. Differences among levels of the variables were evaluated using standardized residuals. Nurses focused on RP-ADS data and intervention levels, whereas physicians focused on diagnoses and expectations. Clinical goals that integrate these orientations emerged to a greater extent in interdisciplinary rounds. In addition, social context of rounds appears to influence nurse handovers. Unidisciplinary ICU nurse handovers consisted of a series of data- and intervention-related observations, whereas ICU nurse handovers in interdisciplinary ICUs tended to integrate data, interventions and clinical goals. These results are relevant to the design and implementation of clinical communication improvement initiatives and support tools.
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Electronic patient records are becoming more common in critical care. As their design and implementation are optimized for single users rather than for groups, we aimed to understand the differences in interaction between members of a multidisciplinary team during ward rounds using an electronic, as opposed to paper, patient medical record. A qualitative study of morning ward rounds of an intensive care unit that triangulates data from video-based interaction analysis, observation, and interviews. Our analysis demonstrates several difficulties the ward round team faced when interacting with each other using the electronic record compared with the paper one. The physical setup of the technology may impede the consultant's ability to lead the ward round and may prevent other clinical staff from contributing to discussions. We discuss technical and social solutions for minimizing the impact of introducing an electronic patient record, emphasizing the need to balance both. We note that awareness of the effects of technology can enable ward-round teams to adapt their formations and information sources to facilitate multidisciplinary communication during the ward round.
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Multi-disciplinary rounds are a forum for communication and sense-making, and they play a critical role in intensive care to ensure care coordination across specialties and providers. Increased availability of clinical information through computers has made it possible to provide support during rounds. We conducted an observation study to determine ways in which computers may be used during rounds, when users are under time pressure in accessing and manipulating clinical data. A total of fifteen hours of rounds in a pediatric intensive care unit for 47 patients were observed. Factors influencing information transfer during rounds were characterized in three areas: physical, social and cognitive, and supporting artifacts. Based on these factors we developed a set of design guidelines for computerized supporting tools. An example guideline suggests digital capture of handwritten notes. These guidelines developed may help guide future systems development, thus leveraging the power of computing during the critical moments of multi-disciplinary rounds.
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This study evaluated the cost-avoidance and clinical benefits gained from pharmacist involvement in focused rounding in the cardiovascular intensive care unit (CICU). A pharmacy salary of $25/hour was assumed, and recommendations for added therapy or increased doses of drug therapy were assessed as costs to the department. Pharmacist-recommended and department- accepted interventions related to discontinuing therapy, switching to more cost-effective therapy, or altering the dosage based on creatinine clearance or overdose were assessed in terms of cost-avoidance to the department. Other interventions were collected, but no related cost impact was reported. Overall, 95% of interventions were accepted. Pharmacy labor cost for time invested was $887, whereas the resulting cost-avoidance to the drug budget was $3,106 (avoided drug costs of $3,202 minus increased drug costs of $96). The final cost savings of $2,218 represented a favorable economic outcome. Other, clinical benefits were derived from focused rounding in the CICU. The authors conclude that pharmacist rounding in the CICU can lead to improved drug therapy and save enough money to offset the cost of the service.
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Quality and efficacy control in the area of critical care medicine also includes a requirement for an analysis of clinical activities. To date, little experience has been gained in the performance of such analysis. With the aid of a mobile data-collecting device, we recorded all the activities of physicians engaged in morning patient care, over a period of 41 working days, covering a total of just on 90 hours. The median duration for a routine care programme is 41 minutes and is broken down as follows: 40% for documentation, 29% for information collection, 26% for patient treatment, and 5% for communication with colleagues. Improvements in efficacy may be expected in particular in the areas of documentation and the search for information in the patient's medical record.
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Objectives: The purpose of this study was to investigate the nature and causes of human errors in the intensive care unit (ICU), adopting approaches proposed by human factors engineering. The basic assumption was that errors occur and follow a pattern that can be uncovered. Design: Concurrent incident study. Setting: Medical-surgical ICU of a university hospital. Measurements and main results: Two types of data were collected: errors reported by physicians and nurses immediately after an error discovery; and activity profiles based on 24-h records taken by observers with human engineering experience on a sample of patients. During the 4 months of data collection, a total of 554 human errors were reported by the medical staff. Errors were rated for severity and classified according to the body system and type of medical activity involved. There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day. Conclusions: A significant number of dangerous human errors occur in the ICU. Many of these errors could be attributed to problems of communication between the physicians and nurses. Applying human factor engineering concepts to the study of the weak points of a specific ICU may help to reduce the number of errors. Errors should not be considered as an incurable disease, but rather as preventable phenomena.
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On March 1, 2001, the Institute of Medicine released Crossing the Quality Chasm: A New Health System for the 21st Century. This is the second and final report by the institute’s Committee for Health Care Quality in America. Highlights of this latest report are summarized in this article.
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The aim of this qualitative study was to explore experience in nurses’ interdisciplinary/interprofessional communication on an intensive care unit. The structure of communication and influencing factors were shown and interpreted from the perspective of the nurses. Nurses working on an internal medical intensive care unit at a teaching facility in central Germany were questioned by means of semi-structured interviews. One main result was that for nurses the culture of communication in the investigation unit was characterized primarily by hierarchical structures imposed by the physicians. This dominance was identified in all nursing activities resulting in a considerable adverse effect on the flow of information concerning the patient between nurses and physicians. Especially within the context of daily rounds nurses were confronted with barriers to participate actively with their knowledge and professional competence in the process of decision-making. The problems described are well known in everyday nursing practice and have been dealt with in the English research literature. However, this study’s aim is to present and summarize the gained insights and to transfer them in a practice-oriented way into a selected field of work. Possible solutions for the problems of inter-professional communication are suggested in subsequent work steps in order to optimize patient care.
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Each year in the United States, 195 000 individuals die as a result of medical mistakes. Communication among health care providers is repeatedly cited as the core principle in effecting patient care outcomes. Regrettably, well-intentioned nurses in the neonatal intensive care unit (NICU) often fail to speak up during patient care rounds (PCRs). The purposes of this study were to determine the perceived barriers and organizational factors that influence nurses' participation in PCRs and to determine the health care team member's perceptions of the nurses' contributions to patient management decisions within these rounds. A descriptive study using the Delphi technique that involves a series of surveys to develop group consensus was used to identify barriers, organizational factors, and contributions of nurses during PCRs. A convenience, all-inclusive sample of interdisciplinary health care team members who routinely participate in PCRs in the NICU in one large tertiary care urban hospital located in the southwestern United States was recruited to participate in the study. Eighty-seven health care team members participated in the final round of the study. Data demonstrated that nurses tend to be indifferent regarding satisfaction with their presence and level of contributions during PCRs. Data suggest that physicians tend to be dissatisfied if nurses are not physically present during rounds, but when nurses are present, they are satisfied with their level of participation and contributions to PCRs. The 2 most important barriers to nurses' participation in PCRs were other patient responsibilities and lack of a standard time for PCRs. For optimal participation, data demonstrated that PCRs should occur at the bedside, the nurse must be available to participate, and the nurse must feel that his/her input is valued and respected. Data demonstrated that more than 98% of participants agreed that nurses make important contributions to PCRs including the infant's response to interventions/medications, feeding issues, and patient advocacy. These data constitute the first step in understanding the barriers and organizational factors that would positively influence nurses' participation in PCRs. The long-term aim of this study is to help health care providers in the NICU engage more effectively and hold crucial conversations in PCRs that ultimately improve patient outcomes and expand staff and organizational effectiveness.
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It is unknown if multidisciplinary clinical rounds provide a greater degree of satisfaction among the professionals than the traditional work methods. The objective was to compare the satisfaction of the physicians and nurses who evaluate the patients jointly with those of the professionals who do so separately and transmit the information «at bedside» (traditional method). An anonymous survey that examined eleven dimensions of expectations, motivation and satisfaction on the common work method was used. Greater global satisfaction was observed in regards to the joint work method both with the substitute nurses (8.3± 0.8 versus 3.1 ± 2.8; p < 0.001) as well as those of the staff (7.2 ± 1.3 versus 2.1 ± 1.3; p = 0.01). In the remaining dimensions examined, the scores of the professionals who participated in the joint clinical rounds were also significantly better. Among the physicians, there were no significant differences in the different dimensions or in the global satisfaction. As a conclusion, it can be stated that the joint and consensual work method for the assessment of the patients produces an improvement in all the dimensions of satisfaction, expectations, and professional performance in the nursing area that is not detected among the physicians.
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Combat casualty care is distributed across professions and echelons of care. Communication within it is fragmented, inconsistent, and prone to failure. Daily checklists used during intensive care unit (ICU) rounds have been shown to improve compliance with evidence-based practices, enhance communication, promote consistency of care, and improve outcomes. Checklists are criticized because it is difficult to establish a causal link between them and their effect on outcomes. We investigated how checklists used during ICU rounds affect communication. We conducted this project in two military ICUs (burn and surgical/trauma). Checklists contained up to 21 questions grouped according to patient population. We recorded which checklist items were discussed during rounds before and after implementation of a "must address" checklist and compared the frequency of discussing items before checklist prompting. Patient discussions addressed more checklist items before prompting at the end of the 2-week evaluation compared with the 2-week preimplementation period (surgical trauma ICU, 36% vs. 77%, p < 0.0001; burn ICU, 47% vs. 72 %, p < 0.001). Most items were addressed more frequently in both ICUs after implementation. Key items such as central line removal, reduction of laboratory testing, medication reconciliation, medication interactions, bowel movements, sedation holidays, breathing trials, and lung protective ventilation showed significant improvements. Checklists modify communication patterns. Improved communication facilitated by checklists may be one mechanism behind their effectiveness. Checklists are powerful tools that can rapidly alter patient care delivery. Implementing checklists could facilitate the rapid dissemination of clinical practice changes, improve communication between echelons of care and between individuals involved in patient care, and reduce missed information.
Chapter
Systematic review: its origins and contributionThe research question: how do you spread good ideas?“Normal science”, paradigms, and research traditionsMeta-narrative mapping: developing the techniqueSome examples of meta-narratives on the spread of innovationsMeta-narrative mapping: a template for applying it more generallyAn invitation to develop the techniqueAcknowledgement
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• This paper describes the participation of critical care nurses in ward rounds, and explores the power relations associated with the ways in which nurses interact with doctors during this oral forum of communication. • The study comprised a critical ethnographic study of six registered nurses working in a critical care unit. • Data collection methods involved professional journalling, participant observation, and individual and focus group interviews with the six participating nurses. • Findings demonstrated that doctors used nurses to supplement information and provide extra detail about patient assessment during ward rounds. Nurses experienced enormous barriers to participating in decision-making activities during ward round discussions. • By challenging the different points of view that doctors and nurses might hold about the ward round process, the opportunity exists for enhanced participation by nurses.
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Family-centered care has become the new trend in the health care field that involves honoring the patient and families' perspectives and choices and supporting them in participating in care and decision making at whatever level they choose. Family presence on rounds is one of the guidelines instituted for evidence-based best practices for support of family in the delivery of patient-centered care in the intensive care unit (ICU) but identified as the least studied among all the other aspects of family-centered care in the ICU. From 1988 to 2010, only 1 research study on family presence was conducted in an adult ICU. The purpose of this article was to review research studies related to family presence on medical rounds; reviews that focus on both adults and pediatric patients in the critical and noncritical care settings are also included.
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The incidence of ventilator-associated pneumonia (VAP) in trauma patients can be decreased with use of the ventilator bundle (VAPB). Our VAP rate remained high despite the adoption of the VAPB. To better implement the VAPB, a multidisciplinary team composed of the surgical intensive care unit (SICU) nursing staff, physician, and respiratory therapist reviewed briefly a checklist of VAPB goals for each patient before morning attending rounds. We hypothesized that such daily goal rounds (GR) focused on the VAPB would decrease the VAP rate. A pre-GR ten-month period (November 2006 to August 2007) was compared with the ten-month period (September 2007 to June 2008) with daily GRs. The occurrence of VAPs was tallied prospectively in all intubated trauma patients using the National Nosocomial Infection Surveillance criteria. Patient characteristics and outcome data were obtained from our trauma registry and medical records. Patient characteristics were similar in the 85 pre-GR patients and the 89 GR patients. The number of VAPs decreased 67% in the GR patients (15 pre-GR vs. 5 GR; p=0.02); however, the all-cause mortality rate remained similar (16.5% vs. 21.3%; p=0.41). When patients were divided into those with and without VAP, there was a significant increase in mean ventilator, SICU, and hospital days in patients with VAP (p=0.01 for all). There were only two deaths among trauma patients with VAP. Daily multidisciplinary GRs focused on the VAPB can decrease the incidence of VAP significantly in trauma patients. Ventilator-associated pneumonia correlated with extended mean ventilator, SICU, and hospital days. Interestingly, despite a significant decrease in VAP, a decrease in the mortality rate was not observed. Given the small number of deaths in the VAP cohort, this study has insufficient statistical power to elucidate the true impact of GR intervention or VAP on the mortality rate in trauma patients.
Picture Archiving and Communication Systems (PACS) allow the fast delivery of imaging studies to clinicians at the point-of-care, supporting quicker decision-making. PACS has the potential to have a significant impact in the Intensive Care Unit (ICU) where critical decisions are made on a daily basis, particularly during ward rounds. We aimed to examine how accessing image information is integrated into ward rounds and if the presence of PACS produced innovations in ward round practices. We observed ward rounds and conducted interviews with ICU doctors at three hospitals with differing levels of PACS availability and computerization. Imaging results were infrequently viewed by clinicians during ward rounds in two ICUs: one without PACS and one which had both PACS and bedside computers. In the third ICU, where PACS was only available at a central workstation, images were frequently viewed throughout the daily round and integrated into decisions about patient care. The presence of bedside computers does not automatically result in innovations to work practice. Despite the ability to utilize PACS at the bedside to support decision-making, use was varied. Research to understand how the complexities and context of the ICU contribute to work practice innovation and why practice changes differ is required.
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To improve communication during daily rounds using sequential interventions. Prospective cohort study. Multidisciplinary pediatric intensive care unit in a university hospital. The multidisciplinary rounding team in the pediatric intensive care unit, including attending physicians, physician trainees, and nurses. Daily rounds on 736 patients were observed over a 9-month period. Sequential interventions were timed 8-12 wks apart: 1) implementing a new resident daily progress note format; 2) creating a performance improvement "dashboard"; and 3) documenting patients' daily goals on bedside whiteboards. After all interventions, team agreement with the attending physician's stated daily goals increased from 56.9% to 82.7% (p < .0001). Mean agreement increased for each provider category: 65.2% to 88.8% for fellows (p < .0001), 55.0% to 83.8% for residents (p < .0001), and 54.1% to 77.4% for nurses (p < .0001). In addition, significant improvements were noted in provider behaviors after interventions. Barriers to communication (bedside nurse multitasking during rounds, interruptions during patient presentations, and group disassociation) were reduced, and the use of communication facilitators (review of the prior day's goals, inclusion of bedside nurse input, and order read-back) increased. The percentage of providers reporting being "very satisfied" or "satisfied" with rounds increased from 42.6% to 78.3% (p < .0001). Shared agreement of patients' daily goals among key healthcare providers can be increased through process-oriented interventions. Improved agreement will potentially lead to improved quality of patient care and reduced medical errors.
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A new framework for critiquing health-related research is presented in this article. More commonly used existing frameworks tend to have been formulated within the quantitative research paradigm. While frameworks for critiquing qualitative research exist, they are often complex and more suited to the needs of students engaged in advanced levels of study. The framework presented in this article addresses both quantitative and qualitative research within one list of questions. It is argued that this assists the 'novice' student of nursing and health-related research with learning about the two approaches to research by giving consideration to aspects of the research process that are common to both approaches and also that differ between quantitative and qualitative research.
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Quality improvement (QI) attempts to change clinician behavior and, through those changes, lead to improved patient outcomes. The methodological quality of studies evaluating the effectiveness of QI interventions is frequently low. Clinicians and others evaluating QI studies should be aware of the risk of bias, should consider whether the investigators measured appropriate outcomes, should be concerned if there has been no replication of the findings, and should consider the likelihood of success of the QI intervention in their practice setting and the costs and possibility of unintended effects of its implementation. This article complements and enhances existing Users' Guides that address the effects of interventions--Therapy, Harm, Clinical Decision Support Systems, and Summarizing the Evidence guides--with an emphasis on issues specific to QI studies. Given the potential for widespread implementation of QI interventions, there is a need for robust study methods in QI research.
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A physician group in a pediatric intensive care unit faced challenges when moving to a larger unit. Challenges included increased time for rounds, nonbillable attending physician hours, poor communication with pediatric intensive care unit staff, and meeting resident physician duty hours and teaching requirements. The purpose of this analysis was to identify waste and opportunities for improvement to improve physician efficiency. Human factor (observational data collection) techniques were used to capture >60 hrs of rounding data. Twelve attending physicians and their rounding teams were shadowed to capture rounds on 130 pediatric intensive care unit patients. Rounding events, times, and patient interactions were recorded. Lean methods and scenario analysis were used to analyze the data and identify opportunities for improvement. Rounding events were categorized to determine value-added and nonvalue-added activities. Value-added activities were subclassified as essential or nonessential to morning rounds. Thirty-bed pediatric intensive care unit in a children's hospital with academic affiliation. PATIENTS OR SUBJECTS: Eight attending pediatric intensivists and their physician rounding teams. Eight attending physician-led rounding teams were observed for 12 rounding events and a total of 130 patient contacts. Large variation existed in the rounding process. Nonessential activities was highly correlated with physician preference and created a wide range in rounding time per patient. Essential activities showed the least variation and represents a "lean process." Scenario analysis was used to determine the impact of removing waste and reallocating the nonessential activities outside of rounds. Results of the analysis indicated that rounds could be reduced by 42% and that plan of care completion would be timelier (decreased from a mean of 157 to 82 mins). In a large physician group, essential activities showed the least variation. Practice variation focused on minimizing nonessential activities could have dramatic impacts on standardizing practice. Further study is indicated to determine whether standardizing rounds to focus on essential activities can lead to more effective processes that require fewer resources while improving outcomes for all stakeholders.
Article
Effective interdisciplinary exchange of patient information is an essential component of safe, efficient, and patient-centered care in the intensive care unit (ICU). Frequent handoffs of patient care, high acuity of patient illness, and the increasing amount of available data complicate information exchange. Verbal communication can be affected by interruptions and time limitations. To supplement verbal communication, many ICUs rely on documentation in electronic health records (EHRs) to reduce errors of omission and information loss. The purpose of this study was to develop a model of EHR interdisciplinary information exchange of ICU common goals. The theoretical frameworks of distributed cognition and the clinical communication space were integrated and a previously published categorization of verbal information exchange was used. 59.5h of interdisciplinary rounds in a neurovascular ICU were observed and five interviews and one focus group with ICU nurses and physicians were conducted. Current documentation tools in the ICU were not sufficient to capture the nurses' and physicians' collaborative decision-making and verbal communication of goal-directed actions and interactions. Clinicians perceived the EHR to be inefficient for information retrieval, leading to a further reliance on verbal information exchange. The model suggests that EHRs should support: (1) information tools for the explicit documentation of goals, interventions, and assessments with synthesized and summarized information outputs of events and updates; and (2) messaging tools that support collaborative decision-making and patient safety double checks that currently occur between nurses and physicians in the absence of EHR support.
Article
The aim of the study was to evaluate the impact of prospective review of significant drug-drug interactions (DDIs) occurring in medical intensive care unit (MICU) patients by the critical care pharmacist participating in patient care rounds on improvement of safer and more efficacious medication use. A prospective consecutive 10-week study was conducted in the MICU, St Luke's/Roosevelt Hospital Center (St Luke's site), New York, NY. This study compared baseline period when clinical pharmacist services were not provided with the period when each patient's profile was reviewed daily during MICU rounds and interactions were minimized. The study examined whether the presence of critical care pharmacist would decrease the number of significant DDIs in the MICU. Impact of decreasing presence of severe DDIs on length of stay (LOS) and discharge status was also evaluated. Having a pharmacist on rounds resulted in statistically significant decrease in number of clinically important interactions requiring therapy modification, rated D-X (Poisson regression B = -1.036; 95% confidence interval, -1.318 to -0.753; P < .01). The coefficient (-1.036) indicates the incidence rate ratio of 0.35, meaning that the presence of clinical pharmacist in MICU rounds decreased DDI rate by 65%. According to the multiple linear regression, lower number of DDIs was associated with shorter LOS (P < .01). Inpatient mortality rate was lower in the intervention group compared with the preintervention group. Number of DDIs was not significantly associated with mortality based on simple regression (P = .45) or multiple regression analysis (P = .09). Implementing a DDI screening procedure results in significantly lower number of important DDI in the MICU and shortens LOS.
Article
The Joint Commission on the Accreditation of Healthcare Organizations reports that communication breakdowns are responsible for 85% of sentinel events in hospitals. Patients in surgical ICUs are the most vulnerable to communication errors. Fellows and residents are an integral part of the surgical ICU team, but little is known about resident-fellow communication and its impact on surgical ICU patient outcomes. The objective of this study is to describe resident-fellow patient care communication patterns in the surgical ICU and correlate established communication patterns with short-term outcomes. A prospective observational trial was conducted for 136 consecutive surgical ICU days. We evaluated resident-fellow communication of four cardiorespiratory events: hypotension, new arrhythmias, tachypnea, and desaturation. We prospectively defined three short-term outcomes: improved, not improved, and worse. An intervention was attempted to improve communication. Three hundred twelve events were collected (166 observational and 146 interventional). PGY3 residents covered approximately 60% of days in both phases. PGY3 residents were responsible for 73% of communication errors in the observational phase and 59% of communication errors in the interventional phase. Communication errors were more likely in the late shift (p < 0.0001). The late shift was responsible for 77% of all communication errors. Communication errors resulted in worse short-term outcomes for cardiorespiratory events (p < 0.0002). Effective communication was a significant predictor of improved short-term outcomes (p < 0.0003). The intervention decreased communication errors in the late shift by 10% (p < 0.052). Communication errors occurred more frequently during the late shift. These communication errors were associated with worsened short-term outcomes. Improved communication in the surgical ICU is a fruitful target to improve clinical outcomes.
Article
To examine the effect of online counseling abuse counseling on drug use among underserved patients. Subjects were recruited from an Indian Reservation in Eagle Butte, South Dakota; a family court in Newark, New Jersey; a probation office in Alexandria, Virginia; and a co-occurring disorders treatment clinic in Washington, District of Columbia. Subjects were predominantly poor, undereducated, unemployed, court involved, or diagnosed with co-occurring psychiatric disorders. A total of 79 subjects volunteered to participate in the project. Subjects were randomly assigned to either a control group or an experimental group. The control and experimental groups were both issued an Internet-ready computer and 1 year of Internet service. Only the experimental group had access to online counseling intervention. Drug use was measured using a combination of self-usage reporting and supervised urine tests. Urine tests were available for 37% of subjects. Exit surveys containing self-reported usage were obtained from 54% of the subjects. Self-usage reports or urine test results were available from 70% of subjects. The difference of the rates of drug use in the control and experimental groups (as calculated from urine tests or through self-report) was not significantly different from zero, suggesting that online counseling had not led to a reduction in substance use. It is possible that the study lacked sufficient power to detect small differences in the rate of drug use in the experimental and control groups. Additional research is needed to establish the efficacy of online counseling in hard-to-reach populations.