Standardizing communication from acute care providers to primary care providers on critically ill adults.

PubMed

Ellis, Kerri A; Connolly, Ann; Hosseinnezhad, Alireza; Lilly, Craig M

2015-11-01

To increase the frequency of communication of patient information between acute and primary care providers. A secondary objective was to determine whether higher rates of communication were associated with lower rates of hospital readmission 30 days after discharge. A validated instrument was used for telephone surveys before and after an intervention designed to increase the frequency of communication among acute care and primary care providers. The communication intervention was implemented in 3 adult intensive care units from 2 campuses of an academic medical center. The frequency of communication among acute care and primary care providers, the perceived usefulness of the intervention, and its association with 30-day readmission rates were assessed for 202 adult intensive care episodes before and 100 episodes after a communication intervention. The frequency of documented communication increased significantly (5/202 or 2% before to 72/100 or 72% after the intervention; P < .001) and the communication was considered useful by every participating primary care provider. Rates of rehospitalization at 30 days were lower for the intervention group than the preintervention group, but the difference was not statistically significant (41/202 or 23% vs 16/88 or 18% of discharged patients; P = .45; power 0.112 at P = .05). The frequency of communication episodes that provide value can be increased through standardized processes. The key aspects of this effective intervention were setting the expectation that communication should occur, documenting when communication has occurred, and reviewing that documentation during multiprofessional rounds. ©2015 American Association of Critical-Care Nurses.

Temporal and subjective work demands in office-based patient care: an exploration of the dimensions of physician work intensity.

PubMed

Jacobson, C Jeff; Bolon, Shannon; Elder, Nancy; Schroer, Brian; Matthews, Gerald; Szaflarski, Jerzy P; Raphaelson, Marc; Horner, Ronnie D

2011-01-01

Physician work intensity (WI) during office-based patient care affects quality of care and patient safety as well as physician job-satisfaction and reimbursement. Existing, brief work intensity measures have been used in physician studies, but their validity in clinical settings has not been established. Document and describe subjective and temporal WI dimensions for physicians in office-based clinical settings. Examine these in relation to the measurement procedures and dimensions of the SWAT and NASA-TLX intensity measures. A focused ethnographic study using interviews and direct observations. Five family physicians, 5 general internists, 5 neurologists, and 4 surgeons. Through interviews, each physician was asked to describe low and high intensity work responsibilities, patients, and events. To document time and task allotments, physicians were observed during a routine workday. Notes and transcripts were analyzed using the editing method in which categories are obtained from the data. WI factors identified by physicians matched dimensions assessed by standard, generic instruments of work intensity. Physicians also reported WI factors outside of the direct patient encounter. Across specialties, physician time spent in direct contact with patients averaged 61% for office-based services. Brief work intensity measures such as the SWAT and NASA-TLX can be used to assess WI in the office-based clinical setting. However, because these measures define the physician work "task" in terms of effort in the presence of the patient (ie, intraservice time), substantial physician effort dedicated to pre- and postservice activities is not captured.

Factors contributing to the process of intensive care patient discharge: an ethnographic study informed by activity theory.

PubMed

Lin, Frances; Chaboyer, Wendy; Wallis, Marianne; Miller, Anne

2013-08-01

Patient flow from intensive care to acute care units is often problematic and many discharges from intensive care to acute care are unsuccessful on the first attempt. The aim of this study was to explore the factors that influence intensive care patient discharge. This ethnographic study was undertaken in an Australian metropolitan tertiary hospital that had a 14-bed level 3 intensive care unit. Intensive care and acute care unit medical and nursing staff, and other hospital staff who were involved in the intensive care patient discharge process participated in this study. A total of 28 discharges were observed, and 56 one on one interviews were conducted. Data collection techniques including direct observations, semi-structured interviews, and collection of existing documents were used. Activity theory was the theoretical framework that underpinned this study. Three patient activity systems were identified: intensive care patient discharge activity, acute care unit accepting patient activity, and hospital bed management activity. Analysis of the interactions among these activity systems revealed conflicting objects (goals), communication breakdowns, and teamwork issues. Discharge delay was found to be a significant problem, which was associated with limited acute care unit bed availability. Strategies to improve acute care unit bed availability are needed. Routine after-hours ICU discharge could raise patient safety concerns which need to be considered. All team members' input in discharge decision making should be encouraged. Problems identified in clinical handover call for actions to change the handover practice. Activity theory successfully guided the study by providing a practical and descriptive framework for the study, facilitating the understanding of the interrelationships among the activity systems. Copyright © 2012 Elsevier Ltd. All rights reserved.

Impact of computerized information systems on workload in operating room and intensive care unit.

PubMed

Bosman, R J

2009-03-01

The number of operating rooms and intensive care departments equipped with a clinical information system (CIS) is rapidly expanding. Amongst the putative advantages of such an installation, reduction in workload for the clinician is one of the most appealing. The scarce studies looking at workload variations associated with the implementation of a CIS, only focus on direct workload discarding indirect changes in workload. Descriptions of the various methods to quantify workload are provided. The hypothesis that a third generation CIS can reduce documentation time for ICU nurses and increase time they spend on patient care, is supported by recent literature. Though it seems obvious to extrapolate these advantages of a CIS to the anesthesiology department or physicians in the intensive care, studies examining this assumption are scarce.

Physical and rehabilitation medicine (PRM) care pathways: adults with severe traumatic brain injury.

PubMed

Pradat-Diehl, P; Joseph, P-A; Beuret-Blanquart, F; Luauté, J; Tasseau, F; Remy-Neris, O; Azouvi, P; Sengler, J; Bayen, É; Yelnik, A; Mazaux, J-M

2012-11-01

This document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients' clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. 'Care pathways in PRM' is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients' optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients' needs. Copyright © 2012. Published by Elsevier Masson SAS.

Transition to intensive care nursing: establishing a starting point.

PubMed

Boyle, Martin; Butcher, Rand; Conyers, Vicki; Kendrick, Tina; MacNamara, Mary; Lang, Susie

2008-11-01

There is a shortage of intensive care (IC) nurses. A supported transition to IC nursing has been identified as a key strategy for recruitment and retention. In 2004 a discussion document relating to transition of IC nurses was presented to the New South Wales (NSW) Chief Nursing Officer (CNO). A workshop was held with key stakeholders and a Steering Group was established to develop a state-wide transition to IC nursing program. To survey orientation programs and educational resources and develop definitions, goals, learning objectives and clinical competencies relating to transition to IC nursing practice. A questionnaire and a draft document of definitions, target group, goals, learning objectives and clinical competencies for IC transition was distributed to 43 NSW IC units (ICUs). An iterative process of anonymous feedback and modification was undertaken to establish agreement on content. Responses were received from 29 units (return rate of 67%). The survey of educational resources indicated ICUs had access to educational support and there was evidence of a lack of a common standard or definition for "orientation" or "transition". The definitions, target group, goals and competency statements from the draft document were accepted with minor editorial change. Seventeen learning objectives or psychomotor skills were modified and an additional 19 were added to the draft as a result of the process. This work has established valid definitions, goals, learning objectives and clinical competencies that describe transition to intensive care nursing.

Advance Directives and Powers of Attorney in Intensive Care Patients.

PubMed

de Heer, Geraldine; Saugel, Bernd; Sensen, Barbara; Rübsteck, Charlotte; Pinnschmidt, Hans O; Kluge, Stefan

2017-06-05

Advance directives and powers of attorney are increasingly common, yet data on their use in clinical situations remain sparse. In this single center cross-sectional study, we collected data by questionnaire from 1004 intensive care patients in a university hospital. The frequencies of advance directives and powers of attorney were determined, and the factors affecting them were studied with multivariate logistic regression analysis. Usable data were obtained from 998 patients. 51.3% stated that they had prepared a document of at least one of these two kinds. Among them, 39.6% stated that they had given the relevant document(s) to the hospital, yet such documents were present in the patient's hospital record for only 23%. 508 patients stated their reasons for preparing an advance directive or a power of attorney: the most common reason (48%) was the fear of being at other people's mercy, of the lack of self-determination, or of medical overtreatment. The most important factors associated with a patient's statement that he/she had prepared such a document were advanced age (advance directive: 1.022 [1.009; 1.036], p = 0.001; power of attorney: 1.027 [1.014; 1.040], p<0.001) and elective admission to the hospital (advance directive: 1.622 [1.138; 2.311], p<0.007; power of attorney: 1.459 [1.049; 2.030], p = 0.025). 39.8% of the advance directives and 44.1% of the powers of attorney that were present in the hospital records were poorly interpretable because of the incomplete filling-out of preprinted forms. Half of the patients who did not have such a document had already thought of preparing one, but had not yet done so. For patients hospitalized in intensive care units, there should be early discussion about the presence or absence of documents of these kinds and early evaluation of the patient's concrete wishes in critical situations. Future studies are needed to determine how best to assure that these documents will be correctly prepared and then given over to hospital staff so that they can take their place in the patient's record.

[Descriptive Analysis of Health Economics of Intensive Home Care of Ventilated Patients].

PubMed

Lehmann, Yvonne; Ostermann, Julia; Reinhold, Thomas; Ewers, Michael

2018-05-14

Long-term ventilated patients in Germany receive intensive care mainly in the patients' home or in assisted-living facilities. There is a lack of knowledge about the nature and extent of resource use and costs associated with care of this small, heterogeneous but overall growing patient group. A sub-study in the context of a research project SHAPE analyzed costs of 29 patients descriptively from a social perspective. Direct and indirect costs of intensive home care over a period of three months were recorded and analyzed retrospectively. Standardized recorded written self-reports from patients and relatives as well as information from the interviewing of nursing staff and from nursing documentation were the basis for this analysis. There was an average total cost of intensive home care for three months per patient of 61194 € (95% CI 53 884-68 504) including hospital stays. The main costs were directly linked to outpatient medical and nursing care provided according to the Code of Social Law V and XI. Services provided by nursing home care service according to § 37(2) Code of Social Law V (65%) were the largest cost item. Approximately 13% of the total costs were attributable to indirect costs. Intensive home care for ventilated patients is resource-intensive and cost-intensive and has received little attention also from a health economics perspective. Valid information and transparency about the cost structures are required for an effective and economic design and management of the long-term care of this patient group. © Georg Thieme Verlag KG Stuttgart · New York.

[The German DRG system 2003-2010 from the perspective of intensive care medicine].

PubMed

Franz, Dominik; Bunzemeier, Holger; Roeder, Norbert; Reinecke, Holger

2010-01-01

Intensive care medicine is extremely heterogeneous, expensive and can only be partially planned and controlled. A correct and fair representation of intensive care medicine in the G-DRG system is an essential requirement for the use as a pricing system. From the perspective of intensive care medicine, pertinent changes of the DRG structure and differentiation of relevant parameters have been established within the G-DRG systems 2003-2010. Analysis of relevant diagnoses, medical procedures, co-payment structures and G-DRGs in the versions 2003-2010 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Since the first G-DRG system version 2003, numerous measures improved quality of case allocation of intensive care medicine. Highly relevant to the system version 2010 are duration of mechanical ventilation, the intensive care treatment complex and complicating constellations. The number of G-DRGs relevant to intensive medical care increased from n = 3 (2003) to n = 58 (2010). For standard cases, quality of case allocation and G-DRG reimbursement are adequate in 2010. The G-DRG system gained complexity again. High demands are made on correct and complete coding of complex cases. Nevertheless, further adjustments of the G-DRG system especially for cases with extremely high costs are necessary. Where the G-DRG system is unable to cover extremely high-cost cases, reimbursement solutions beyond the G-DRG structure should be taken into account.

The role of advance directives in end-of-life decisions in Austria: survey of intensive care physicians.

PubMed

Schaden, Eva; Herczeg, Petra; Hacker, Stefan; Schopper, Andrea; Krenn, Claus G

2010-10-21

Currently, intensive care medicine strives to define a generally accepted way of dealing with end-of-life decisions, therapy limitation and therapy discontinuation.In 2006 a new advance directive legislation was enacted in Austria. Patients may now document their personal views regarding extension of treatment. The aim of this survey was to explore Austrian intensive care physicians' experiences with and their acceptance of the new advance directive legislation two years after enactment (2008). Under the aegis of the OEGARI (Austrian Society of Anaesthesiology, Resuscitation and Intensive Care) an anonymised questionnaire was sent to the medical directors of all intensive care units in Austria. The questions focused on the physicians' experiences regarding advance directives and their level of knowledge about the underlying legislation. There were 241 questionnaires sent and 139 were turned, which was a response rate of 58%. About one third of the responders reported having had no experience with advance directives and only 9 directors of intensive care units had dealt with more than 10 advance directives in the previous two years. Life-supporting measures, resuscitation, and mechanical ventilation were the predominantly refused therapies, wishes were mainly expressed concerning pain therapy. A response rate of almost 60% proves the great interest of intensive care professionals in making patient-oriented end-of-life decisions. However, as long as patients do not make use of their right of co-determination, the enactment of the new law can be considered only a first important step forward.

Evaluation of a Behavioral Self-Care Intervention for Public Health Students

ERIC Educational Resources Information Center

White, Marney A.; Mayer, Margaret; Vanderlind, W. Michael; Allswede, Dana

2018-01-01

Background: Postgraduate education is recognized as a time of intense stress. Rates of anxiety and depression are elevated among graduate students, and longitudinal studies have documented increases in clinical symptoms over the course of training. Purpose: The current study was to evaluate whether an academically sponsored self-care intervention…

Partnering With a Family Advisor to Improve Communication in a Pediatric Intensive Care Unit.

PubMed

Czulada, Laura; Leino, Patience; Willis, Tina Schade

2016-11-01

Inadequate communication between medical teams and families can lead to errors and poor-quality care. The objective was to understand why communication between the clinical team and families was not occurring consistently in the pediatric intensive care unit and improve the system using a multidisciplinary improvement team including a family advisor. This improvement project used Lean Six Sigma. The team observed updates and collected documented communication, survey, interview, and focus group data from families and staff. Root causes of failures included lack of assigned responsibility, lack of defined daily update, and lack of a daily communication standard. Process changes were implemented, resulting in an increased mean documented communication rate from 13% pre intervention to 65% post intervention that was sustained for more than 2 years (P < .001). Including a family advisor as an equal member of an improvement team provides family empowerment and a greater chance of success in complex areas. © The Author(s) 2015.

Thermal equipment usage patterns in neonatal intensive care units: interunit variability and intraunit consistency.

PubMed

Seguin, J; Hayes, J

1997-05-01

We conducted a survey and audit of thermal equipment use in very low-birth-weight infants in five Ohio neonatal intensive care units (NICUs) to document regional practice. The survey indicated a variety of thermal care styles. Two NICUs preferred to admit infants to incubators, the other three favoring radiant warmers. These three NICUs moved infants from radiant warmers into incubators at significantly different mean ages. The audit demonstrated inconsistent use of plastic covers, warming mattresses, and added humidity under radiant warmers, and discrepancies between survey responses and actual use within NICUs. Inter-NICU variability of thermal equipment use may complicate fluid management.

Regional variations in health care intensity and physician perceptions of quality of care.

PubMed

Sirovich, Brenda E; Gottlieb, Daniel J; Welch, H Gilbert; Fisher, Elliott S

2006-05-02

Research has documented dramatic differences in health care utilization and spending across U.S. regions with similar levels of patient illness. Although patient outcomes and quality of care have been found to be no better in regions of high health care intensity, it is unknown whether physicians in these regions feel more capable of providing good patient care than those in low-intensity regions. To determine whether physicians in high-intensity regions feel better able to care for patients than physicians in low-intensity regions. Physician telephone survey. 51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample. 10,577 physicians who provided care to adults in 1998 or 1999 were surveyed for the Community Tracking Study (response rate, 61%). The End-of-Life Expenditure Index, a measure of spending that reflects differences in the overall quantity of medical services provided rather than differences in illness or price, was used to determine health care intensity in the physicians' community. Outcomes included physicians' perceived availability of clinical services, ability to provide high-quality care to patients, and career satisfaction. Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients. The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity region (P < 0.001 for the relationship between intensity and perceived ability to obtain hospital admissions); the proportion of physicians who felt able to obtain high-quality specialist referrals ranged from 64% in high-intensity regions to 79% in low-intensity regions (P < 0.001). Compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships (range, 62% to 70%; P < 0.001) or able to provide high-quality care (range, 72% to 77%; P = 0.009). In most cases, differences persisted but were attenuated in magnitude after adjustment for physician attributes, practice characteristics, and local market factors (for example, managed care penetration); the difference in perceived ability to provide high-quality care was no longer statistically significant (P = 0.099). The cross-sectional design prevented demonstration of a causal relationship between intensity and physician perceptions of quality. Despite more resources, physicians in regions of high health care intensity did not report greater ease in obtaining needed services or greater ability to provide high-quality care.

A Technical Evaluation of Wireless Connectivity from Patient Monitors to an Anesthesia Information Management System During Intensive Care Unit Surgery.

PubMed

Simpao, Allan F; Galvez, Jorge A; England, W Randall; Wartman, Elicia C; Scott, James H; Hamid, Michael M; Rehman, Mohamed A; Epstein, Richard H

2016-02-01

Surgical procedures performed at the bedside in the neonatal intensive care unit (NICU) at The Children's Hospital of Philadelphia were documented using paper anesthesia records in contrast to the operating rooms, where an anesthesia information management system (AIMS) was used for all cases. This was largely because of logistical problems related to connecting cables between the bedside monitors and our portable AIMS workstations. We implemented an AIMS for documentation in the NICU using wireless adapters to transmit data from bedside monitoring equipment to a portable AIMS workstation. Testing of the wireless AIMS during simulation in the presence of an electrosurgical generator showed no evidence of interference with data transmission. Thirty NICU surgical procedures were documented via the wireless AIMS. Two wireless cases exhibited brief periods of data loss; one case had an extended data gap because of adapter power failure. In comparison, in a control group of 30 surgical cases in which wired connections were used, there were no data gaps. The wireless AIMS provided a simple, unobtrusive, portable alternative to paper records for documenting anesthesia records during NICU bedside procedures.

Computerized clinical documentation system in the pediatric intensive care unit

PubMed Central

2001-01-01

Background To determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity. Methods Before and after implementation of CDS, a time study involving nursing care, medication delivery, and normalization of serum calcium and potassium values was performed. In addition, an evaluation of completeness of documentation and a clinician survey of shift to shift reporting were also completed. This was a modified one group, pretest-posttest design. Results With the CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable. Conclusions When compared to a paper chart, the CDS provided a more legible, compete, and accessible patient record without affecting time spent in direct patient care. The availability of the CDS improved shift to shift reporting. Other observations showed that the CDS improved management capabilities; helped physicians deliver care; improved reimbursement; limited data entry errors; and reduced costs. PMID:11604105

Materials on Nursing in the Clearinghouse: Bibliography #16, and Neonatal Intensive Care Units: Bibliography #17.

ERIC Educational Resources Information Center

Illinois Public Health Association, Springfield.

The first of the two bibliographies in this document contains 38 entries on neonatal nursing, including books and journal articles (originally published from 1973 to 1986) dealing with such topics as high-risk pregnancy and delivery, home care of developmentally disabled newborns, and family dynamics. The second bibliography, titled "Neonatal…

The Changing Role of Palliative Care in the ICU

PubMed Central

Aslakson, Rebecca A.; Curtis, J. Randall; Nelson, Judith E.

2015-01-01

Objectives Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation. Data Sources We searched the MEDLINE database from inception through January 2014. We also searched the Reference Library of The Improving Palliative Care in the ICU Project website sponsored by the National Institutes of Health and the Center to Advance Palliative Care, which is updated monthly. We hand-searched reference lists and author files. Study Selection Selected studies included all English-language articles concerning adult patients using the search terms "intensive care" or "critical care" with "palliative care," "supportive care," "end-of-life care," or "ethics." Data Extraction After examination of peer-reviewed original scientific articles, consensus statements, guidelines, and reviews resulting from our literature search, we made final selections based on author consensus. Data Synthesis Existing evidence is organized to address: 1) opportunities to alleviate physical and emotional symptoms, improve communication, and provide support for patients and families; 2) models and specific interventions for improving ICU palliative care; 3) available resources for ICU palliative care improvement; and 4) ongoing challenges and targets for future research. Key domains of ICU palliative care have been defined and operationalized as measures of quality. There is increasing recognition that effective integration of palliative care during acute and chronic critical illness may help patients and families face challenges after discharge from intensive care. Conclusions Palliative care is increasingly accepted as an essential component of comprehensive care for critically ill patients, regardless of diagnosis or prognosis. A variety of strategies to improve ICU palliative care appear to be effective, and resources including technical assistance and tools are available to support improvement efforts. As the longer-term impact of intensive care on those surviving acute critical illness is increasingly documented, palliative care can help prepare and support patients and families for challenges after ICU discharge. Further research is needed to inform efforts to integrate palliative care with intensive care more effectively and efficiently in and after the ICU and to document improvement using valid and responsive outcome measures. PMID:25167087

The role of advance directives in end-of-life decisions in Austria: survey of intensive care physicians

PubMed Central

2010-01-01

Background Currently, intensive care medicine strives to define a generally accepted way of dealing with end-of-life decisions, therapy limitation and therapy discontinuation. In 2006 a new advance directive legislation was enacted in Austria. Patients may now document their personal views regarding extension of treatment. The aim of this survey was to explore Austrian intensive care physicians' experiences with and their acceptance of the new advance directive legislation two years after enactment (2008). Methods Under the aegis of the OEGARI (Austrian Society of Anaesthesiology, Resuscitation and Intensive Care) an anonymised questionnaire was sent to the medical directors of all intensive care units in Austria. The questions focused on the physicians' experiences regarding advance directives and their level of knowledge about the underlying legislation. Results There were 241 questionnaires sent and 139 were turned, which was a response rate of 58%. About one third of the responders reported having had no experience with advance directives and only 9 directors of intensive care units had dealt with more than 10 advance directives in the previous two years. Life-supporting measures, resuscitation, and mechanical ventilation were the predominantly refused therapies, wishes were mainly expressed concerning pain therapy. Conclusion A response rate of almost 60% proves the great interest of intensive care professionals in making patient-oriented end-of-life decisions. However, as long as patients do not make use of their right of co-determination, the enactment of the new law can be considered only a first important step forward. PMID:20964852

Barriers to regaining control within a constructivist grounded theory of family resilience in ICU: Living with uncertainty.

PubMed

Wong, Pauline; Liamputtong, Pranee; Koch, Susan; Rawson, Helen

2017-12-01

To discuss families' experiences of their interactions when a relative is admitted unexpectedly to an Australian intensive care unit. The overwhelming emotions associated with the unexpected admission of a relative to an intensive care unit are often due to the uncertainty surrounding the condition of their critically ill relative. There is limited in-depth understanding of the nature of uncertainty experienced by families in intensive care, and interventions perceived by families to minimise their uncertainty are not well documented. Furthermore, the interrelationships between factors, such as staff-family interactions and the intensive care unit environment, and its influence on families' uncertainty particularly in the context of the Australian healthcare system, are not well delineated. A grounded theory methodology was adopted for the study. Data were collected between 2009-2013, using in-depth interviews with 25 family members of 21 critically ill patients admitted to a metropolitan, tertiary-level intensive care unit in Australia. This paper describes the families experiences of heightened emotional vulnerability and uncertainty when a relative is admitted unexpectedly to the intensive care unit. Families uncertainty is directly influenced by their emotional state, the foreign environment and perceptions of being 'kept in the dark', as well as the interrelationships between these factors. Staff are offered an improved understanding of the barriers to families' ability to regain control, guided by a grounded theory of family resilience in the intensive care unit. The findings reveal in-depth understanding of families' uncertainty in intensive care. It suggests that intensive care unit staff need to focus clinical interventions on reducing factors that heighten their uncertainty, while optimising strategies that help alleviate it. Families are facilitated to move beyond feelings of helplessness and loss of control, and cope better with their situation. © 2017 John Wiley & Sons Ltd.

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

PubMed

Byrnes, Matthew C; Schuerer, Douglas J E; Schallom, Marilyn E; Sona, Carrie S; Mazuski, John E; Taylor, Beth E; McKenzie, Wendi; Thomas, James M; Emerson, Jeffrey S; Nemeth, Jennifer L; Bailey, Ruth A; Boyle, Walter A; Buchman, Timothy G; Coopersmith, Craig M

2009-10-01

To determine a) if a checklist covering a diverse group of intensive care unit protocols and objectives would improve clinician consideration of these domains and b) if improved consideration would change practice patterns. Pre- and post observational study. A 24-bed surgical/burn/trauma intensive care unit in a teaching hospital. A total of 1399 patients admitted between June 2006 and May 2007. The first component of the study evaluated whether mandating verbal review of a checklist covering 14 intensive care unit best practices altered verbal consideration of these domains. Evaluation was performed using real-time bedside audits on morning rounds. The second component evaluated whether the checklist altered implementation of these domains by changing practice patterns. Evaluation was performed by analyzing data from the Project IMPACT database after patients left the intensive care unit. Verbal consideration of evaluable domains improved from 90.9% (530/583) to 99.7% (669/671, p < .0001) after verbal review of the checklist was mandated. Bedside consideration improved on the use of deep venous thrombosis prophylaxis (p < .05), stress ulcer prophylaxis (p < .01), oral care for ventilated patients (p < 0.01), electrolyte repletion (p < .01), initiation of physical therapy (p < .05), and documentation of restraint orders (p < .0001). Mandatory verbal review of the checklist resulted in a greater than two-fold increase in transferring patients out of the intensive care unit on telemetry (16% vs. 35%, p < .0001) and initiation of physical therapy (28% vs. 42%, p < .0001) compared with baseline practice. A mandatory verbal review of a checklist covering a wide range of objectives and goals at each patient's bedside is an effective method to improve both consideration and implementation of intensive care unit best practices. A bedside checklist is a simple, cost-effective method to prevent errors of omission in basic domains of intensive care unit management that might otherwise be forgotten in the setting of more urgent care requirements.

Clinical Assessment of Nursing Care Regarding Hemovigilance in Neonatal Wards and Neonatal Intensive Care Units in Selected Hospitals Affiliated to Shahid Beheshti University of Medical Sciences (2013 - 2014)

PubMed Central

Tajalli, Saleheh; Nourian, Manijeh; Rassouli, Maryam; Baghestani, Ahmad Reza

2015-01-01

Background: Hemovigilance is a series of surveillance procedures encompassing the entire transfusion chain from the collection of blood and its components to the follow-up of its recipients. It is intended to collect and access information on unanticipated or adverse effects stemming from the therapeutic use of labile blood products. Blood transfusion, particularly in neonates, requires meticulous clinical assessment to ensure safety before, during, and after the procedure. Therefore, it is essential to investigate how nurses and other health care providers implement hemovigilance with a view to elevating the standards of care. Objectives: The aim of this study, conducted between 2013 and 2014, was to assess nursing care regarding hemovigilance in the neonatal wards and neonatal intensive care units (NICUs) of selected hospitals affiliated to Shahid Beheshti University of Medical Sciences. Materials and Methods: This descriptive study assessed nursing care concerning hemovigilance in 144 neonates. Data were collected using a checklist at the neonatal wards and NICUs of Mahdiyeh, Mofid, and Imam Hussain hospitals affiliated to Shahid Beheshti University of Medical Sciences. The checklist contained information on the standard of care in relation to neonatal hemovigilance in three components of request, transfusion, and documentation. Descriptive statistics with the Statistical Package for the Social Sciences (version 21) were used to analyze the collected data. Results: The rates of compliance with the hemovigilance guidelines in terms of request, transfusion, and documentation were 47%, 63.2%, and 68%, correspondingly, with a total score of 59.6% in all areas of research. Accordingly, compliance with hemovigilance guidelines was highest in documentation (68%), followed by transfusion (63.2%) and request (47%). Conclusions: The overall score of nursing care as regards adherence to the neonatal hemovigilance guidelines was 59.6% in the present study, indicating a lack of care and failure in training in this regard. PMID:26421167

Brazilian recommendations of mechanical ventilation 2013. Part 2

PubMed Central

2014-01-01

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. PMID:25410835

Brazilian recommendations of mechanical ventilation 2013. Part I

PubMed Central

Barbas, Carmen Sílvia Valente; Ísola, Alexandre Marini; Farias, Augusto Manoel de Carvalho; Cavalcanti, Alexandre Biasi; Gama, Ana Maria Casati; Duarte, Antonio Carlos Magalhães; Vianna, Arthur; Serpa, Ary; Bravim, Bruno de Arruda; Pinheiro, Bruno do Valle; Mazza, Bruno Franco; de Carvalho, Carlos Roberto Ribeiro; Toufen, Carlos; David, Cid Marcos Nascimento; Taniguchi, Corine; Mazza, Débora Dutra da Silveira; Dragosavac, Desanka; Toledo, Diogo Oliveira; Costa, Eduardo Leite; Caser, Eliana Bernardete; Silva, Eliezer; Amorim, Fabio Ferreira; Saddy, Felipe; Galas, Filomena Regina Barbosa Gomes; Silva, Gisele Sampaio; de Matos, Gustavo Faissol Janot; Emmerich, João Claudio; Valiatti, Jorge Luis dos Santos; Teles, José Mario Meira; Victorino, Josué Almeida; Ferreira, Juliana Carvalho; Prodomo, Luciana Passuello do Vale; Hajjar, Ludhmila Abrahão; Martins, Luiz Cláudio; Malbouisson, Luiz Marcelo Sá; Vargas, Mara Ambrosina de Oliveira; Reis, Marco Antonio Soares; Amato, Marcelo Brito Passos; Holanda, Marcelo Alcântara; Park, Marcelo; Jacomelli, Marcia; Tavares, Marcos; Damasceno, Marta Cristina Paulette; Assunção, Murillo Santucci César; Damasceno, Moyzes Pinto Coelho Duarte; Youssef, Nazah Cherif Mohamad; Teixeira, Paulo José Zimmermann; Caruso, Pedro; Duarte, Péricles Almeida Delfino; Messeder, Octavio; Eid, Raquel Caserta; Rodrigues, Ricardo Goulart; de Jesus, Rodrigo Francisco; Kairalla, Ronaldo Adib; Justino, Sandra; Nemer, Sérgio Nogueira; Romero, Simone Barbosa; Amado, Verônica Moreira

2014-01-01

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. PMID:25028944

Brazilian recommendations of mechanical ventilation 2013. Part 2

PubMed Central

Barbas, Carmen Sílvia Valente; Ísola, Alexandre Marini; Farias, Augusto Manoel de Carvalho; Cavalcanti, Alexandre Biasi; Gama, Ana Maria Casati; Duarte, Antonio Carlos Magalhães; Vianna, Arthur; Serpa Neto, Ary; Bravim, Bruno de Arruda; Pinheiro, Bruno do Valle; Mazza, Bruno Franco; de Carvalho, Carlos Roberto Ribeiro; Toufen Júnior, Carlos; David, Cid Marcos Nascimento; Taniguchi, Corine; Mazza, Débora Dutra da Silveira; Dragosavac, Desanka; Toledo, Diogo Oliveira; Costa, Eduardo Leite; Caser, Eliana Bernadete; Silva, Eliezer; Amorim, Fabio Ferreira; Saddy, Felipe; Galas, Filomena Regina Barbosa Gomes; Silva, Gisele Sampaio; de Matos, Gustavo Faissol Janot; Emmerich, João Claudio; Valiatti, Jorge Luis dos Santos; Teles, José Mario Meira; Victorino, Josué Almeida; Ferreira, Juliana Carvalho; Prodomo, Luciana Passuello do Vale; Hajjar, Ludhmila Abrahão; Martins, Luiz Claudio; Malbouisson, Luis Marcelo Sá; Vargas, Mara Ambrosina de Oliveira; Reis, Marco Antonio Soares; Amato, Marcelo Brito Passos; Holanda, Marcelo Alcântara; Park, Marcelo; Jacomelli, Marcia; Tavares, Marcos; Damasceno, Marta Cristina Paulette; Assunção, Murillo Santucci César; Damasceno, Moyzes Pinto Coelho Duarte; Youssef, Nazah Cherif Mohamed; Teixeira, Paulo José Zimmermann; Caruso, Pedro; Duarte, Péricles Almeida Delfino; Messeder, Octavio; Eid, Raquel Caserta; Rodrigues, Ricardo Goulart; de Jesus, Rodrigo Francisco; Kairalla, Ronaldo Adib; Justino, Sandra; Nemer, Sergio Nogueira; Romero, Simone Barbosa; Amado, Verônica Moreira

2014-01-01

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. PMID:25295817

Brazilian recommendations of mechanical ventilation 2013. Part I

PubMed Central

2014-01-01

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. PMID:25210957

Sleep of 1- and 2-year-old children in intensive care.

PubMed

Corser, N C

1996-01-01

Physiologic and psychologic changes associated with sleep disturbance decrease the ability of a critically ill child to adapt to hospitalization and thus hamper recovery. Research demonstrates that intensive care settings interfere with sleep of adults, but little is known about the impact of these settings on children's sleep. An exploratory field study was conducted to describe the sleep-wake patterns of 1- and 2-year-old children in intensive care, identify intensive care environmental stimuli associated with sleep and waking states, compare the intensive care sleep-wake pattern to the pre-illness sleep-wake pattern, and determine the time required for children to return to their pre-illness sleep-wake pattern. Twelve children aged 13 to 35 months composed the sample for the study. Pre-illness and postdischarge sleep patterns, sleep patterns during a 12-hour night in the pediatric intensive care unit (PICU), and external and internal environmental stimuli were measured. Prior to hospitalization, subjects demonstrated sleep similar to that documented in healthy children. Children in the PICU experienced a significant loss of sleep, frequent awakenings, and a virtual rapid eye movement (REM) sleep deprivation. External environmental stimuli of light, noise, and caregiver activity were negatively correlated with sleep state. Pain and treatment with benzodiazepines were associated with sleep acquisition. Sleep changes persisted after discharge from the PICU and the hospital. Total sleep time recovered more rapidly than nighttime awakening. Parents perceived that their child's sleep remained different longer than total sleep time and night awakening values demonstrated.

[Intensive medicine in Spain].

PubMed

2011-03-01

Intensive care medicine is a medical specialty that was officially established in our country in 1978, with a 5-year training program including two years of common core training followed by three years of specific training in an intensive care unit accredited for training. During this 32-year period, intensive care medicine has carried out an intense and varied activity, which has allowed its positioning as an attractive and with future specialty in the hospital setting. This document summarizes the history of the specialty, its current situation, the key role played in the programs of organ donation and transplantation of the National Transplant Organization (after more than 20 years of mutual collaboration), its training activities with the development of the National Plan of Cardiopulmonary Resuscitation, with a trajectory of more than 25 years, its interest in providing care based on quality and safety programs for the severely ill patient. It also describes the development of reference registries due to the need for reliable data on the care process for the most prevalent diseases, such as ischemic heart disease or ICU-acquired infections, based on long-term experience (more than 15 years), which results in the availability of epidemiological information and characteristics of care that may affect the practical patient's care. Moreover, features of its scientific society (SEMICYUC) are reported, an organization that agglutinates the interests of more than 280 ICUs and more than 2700 intensivists, with reference to the journal Medicina Intensiva, the official journal of the society and the Panamerican and Iberian Federation of Critical Medicine and Intensive Care Societies. Medicina Intensiva is indexed in the Thompson Reuters products of Science Citation Index Expanded (Scisearch(®)) and Journal Citation Reports, Science Edition. The important contribution of the Spanish intensive care medicine to the scientific community is also analyzed, and in relation to the future of intensive care medicine in Spain and in Europe, recommendations are made towards specialization in intensive care medicine incorporating in the training program those competences (knowledge, skills and attitudes) that should be present an intensivist in Europe and that are extensively fulfilled by the current Spanish training program. The trajectory followed by intensive care medicine in Europe and recently in China, shows the increasing need of intensive care and the progressive recognition of the specialty in economically growing countries, and emphasizes the need of homogenization in the training of future specialists in intensive care medicine globally. Copyright © 2010 Elsevier España, S.L. y SEMICYUC. All rights reserved.

Change of focus: from intensive care towards organ donation.

PubMed

Meyer, Käthe; Bjørk, Ida T

2008-02-01

To progress from identifying a potential organ donor to implementing the actual organ donation effectively is a challenging process for all involved. The nurses might find the change of focus difficult, as the donor organ acquisition process often starts before the relatives had been informed and have had the time to reorient themselves about the severe situation of the patient and have been briefed on the option of organ donation. The purpose was to investigate the hospital-based education in organ donation at the 28 Norwegian donor hospitals, and elicit the needs of the intensive care nurses for imparting of required knowledge and support in shifting their focus from intensive care towards the process of organ procurement. Hospital-based education and guidelines in organ donation were analyzed by scrutinizing the documents available. Eleven units were found to have their own guidelines and only three hospitals had organ donation in their educational programme. Intensive care nurses at three hospitals participated in focus groups. The main finding was the need for collaboration and mutual understanding within the treatment team. Nurses expounded the multiple responsibilities that they discharged during the course of intensive care. In reorienting their focus from intensive care to donor organ procurement, the time of death was explained as the crucial turning point. The knowledge of intensive care staff and professional competence were crucial in winning the relatives' trust and were central in the communication processes. Donor hospitals should implement systematic training and debriefing, where both nurses and physicians contribute to this process. Well-prepared protocols for organ donation at hospitals can define responsibilities assigned to different members of the donor organ acquisition team.

Colonization and infection in the newborn infant: Does chlorhexidine play a role in infection prevention?

PubMed

Ortegón, Lizeth; Puentes-Herrera, Marcela; Corrales, Ivohne F; Cortés, Jorge A

2017-02-01

Healthcare-associated infections are a major problem in newborn infants, considering their high morbidity, mortality, and long-term sequelae. In preterm infants, it has been shown that skin and gastrointestinal tract colonization undergoes variations compared to healthy term infants, and that preterm infants are more exposed to nosocomial microorganisms given their higher probability of being admitted to the neonatal intensive care unit where they are cared for. This document reviews normal colonization, the changes observed during hospitalization, prematurity, and the potential role of chlorhexidine in the prevention of resistant microorganism transmission, as well as its side effects in newborn infants admitted to the neonatal intensive care unit. Sociedad Argentina de Pediatría.

Spiritual and religious components of patient care in the neonatal intensive care unit: sacred themes in a secular setting.

PubMed

Catlin, E A; Guillemin, J H; Thiel, M M; Hammond, S; Wang, M L; O'Donnell, J

2001-01-01

We hypothesized that spiritual distress was a common, unrecognized theme for neonatal intensive care unit (NICU) care providers. An anonymous questionnaire form assigned to a data table in a relational database was designed. Surveys were completed by 66% of NICU staff. All respondents viewed a family's spiritual and religious concerns as having a place in patient care. Eighty-three percent reported praying for babies privately. Asked what theological sense they made of suffering of NICU babies, 2% replied that children do not suffer in the NICU. Regarding psychological suffering of families, the majority felt God could prevent this, with parents differing (p = 0.039) from nonparents. There exists a strong undercurrent of spirituality and religiosity in the study NICU. These data document actual religious and spiritual attitudes and practices and support a need for pastoral resources for both families and care providers. NICU care providers approach difficulties of their work potentially within a religious and spiritual rather than a uniquely secular framework.

Critical care providers refer to information tools less during communication tasks after a critical care clinical information system introduction.

PubMed

Ballermann, Mark; Shaw, Nicola T; Mayes, Damon C; Gibney, R T Noel

2011-01-01

Electronic documentation methods may assist critical care providers with information management tasks in Intensive Care Units (ICUs). We conducted a quasi-experimental observational study to investigate patterns of information tool use by ICU physicians, nurses, and respiratory therapists during verbal communication tasks. Critical care providers used tools less at 3 months after the CCIS introduction. At 12 months, care providers referred to paper and permanent records, especially during shift changes. The results suggest potential areas of improvement for clinical information systems in assisting critical care providers in ensuring informational continuity around their patients.

[Morbidity and mortality after intensive care management of hemorrhagic stroke in Djibouti].

PubMed

Benois, A; Raynaud, L; Coton, T; Petitjeans, F; Hassan, A; Ilah, A; Sergent, H; Grassin, F; Leberre, J

2009-02-01

Prospective data on management and outcome of stroke in Africa is scarce. The purpose of this prospective descriptive study is to present epidemiologic, clinical and outcome data for a series of patients with hemorrhagic stroke in Djibouti. All patients admitted to the intensive care unit of the Bouffard Medical-Surgical Center in Djibouti for cerebral hemorrhage documented by CT-scan of the brain were recruited in this study. A total of 18 patients including 16 men were enrolled. The median patient age in this series was 51.5 years [range, 20-72]. The median duration of intensive care was 3 days [range, 1-38]. Mean Glasgow score at time of admission was 9 [range, 3-14]. Five patients were brought in by emergency medical airlift. The main risk factors for stroke were arterial hypertension, smoking, and regular khat use. Mechanical ventilation was performed in 10 patients with a survival rate of 40%. Six patients (33%) died in the intensive care unit. Hospital mortality within one month was 39% and mortality at 6 months was 44.4%. One-year survival for patients with a Glasgow score < or = 7 at the time of admission was 33%. Arterial hypertension, khat use, and smoking appeared to be major risk factors for male Djiboutians. Neurologic intensive care techniques provided hospital mortality rates similar to those reported in hospitals located in Western countries. Functional outcome in local survivors appeared to be good despite the absence of functional intensive care. These data argue against the passive, fatalistic approach to management of hemorrhagic stroke and for primary prevention of cardiovascular risk factors.

Communication tools for end-of-life decision-making in the intensive care unit: a systematic review and meta-analysis.

PubMed

Oczkowski, Simon J W; Chung, Han-Oh; Hanvey, Louise; Mbuagbaw, Lawrence; You, John J

2016-04-09

For many patients admitted to the intensive care unit (ICU), preferences for end-of-life care are unknown, and clinicians and substitute decision-makers are required to make decisions about the goals of care on their behalf. We conducted a systematic review to determine the effect of structured communication tools for end-of-life decision-making, compared to usual care, upon the number of documented goals of care discussions, documented code status, and decisions to withdraw life-sustaining treatments, in adult patients admitted to the ICU. We searched multiple databases including MEDLINE, Embase, CINAHL, ERIC, and Cochrane from database inception until July 2014. Two reviewers independently screened articles, assessed eligibility, verified data extraction, and assessed risk of bias using the tool described by the Cochrane Collaboration and the Newcastle Ottawa Scale. Pooled estimates of effect (relative risk, standardized mean difference, or mean difference), were calculated where sufficient data existed. GRADE was used to evaluate the overall quality of evidence for each outcome. We screened 5785 abstracts and reviewed the full text of 424 articles, finding 168 eligible articles, including 19 studies in the ICU setting. The use of communication tools increased documentation of goals-of-care discussions (RR 3.47, 95% CI 1.55, 7.75, p = 0.020, very low-quality evidence), but did not have an effect on code status documentation (RR 1.03, 95% CI 0.96, 1.10, p = 0.540, low-quality evidence) or decisions to withdraw or withhold life-sustaining treatments (RR 0.98, 95% CI 0.89, 1.08, p = 0.70, low-quality evidence). The use of such tools was associated with a decrease in multiple measures of health care resource utilization, including duration of mechanical ventilation (MD -1.9 days, 95% CI -3.26, -0.54, p = 0.006, very low-quality evidence), length of ICU stay (MD -1.11 days, 95% CI -2.18, -0.03, p = 0.04, very low-quality evidence), and health care costs (SMD -0.32, 95% CI -0.5, -0.15, p < 0.001, very low-quality evidence). Structured communication tools may improve documentation of EOL decision making and may result in lower resource use. The supporting evidence is low to very low in quality. Further high-quality randomized studies of simple communication interventions are needed to determine whether structured, rather than ad hoc, approaches to end-of-life decision-making improve patient-level, family-level, and system-level outcomes. PROSPERO CRD42014012913.

Rhythmic artifact of physiotherapy in intensive care unit EEG recordings.

PubMed

Young, Bryan; Raihan, Syed; Ladak, H; Kelly, Martin

2007-06-01

Intensive care unit EEG recordings are often contaminated by artifacts that are unseen elsewhere and are usually not documented. One is the rhythmic artifact of physiotherapy (RAP), which can follow the frequency of chest percussion or vibration with either fundamental or harmonic sinusoidal wave forms, affecting single or multiple channels. The occipital electrodes are the most commonly affected, but others can be involved separately or in combination. RAP can easily be mistaken for cerebrally originating rhythms, including seizures. RAP is most easily detected by examining the ECG channel, which usually captures the artifact, but video EEG provides another means, at least for chest percussion.

Does introduction of a Patient Data Management System (PDMS) improve the financial situation of an intensive care unit?

PubMed

Castellanos, Ixchel; Schüttler, Jürgen; Prokosch, Hans-Ulrich; Bürkle, Thomas

2013-09-16

Patient Data Management Systems (PDMS) support clinical documentation at the bedside and have demonstrated effects on completeness of patient charting and the time spent on documentation. These systems are costly and raise the question if such a major investment pays off. We tried to answer the following questions: How do costs and revenues of an intensive care unit develop before and after introduction of a PDMS? Can higher revenues be obtained with improved PDMS documentation? Can we present cost savings attributable to the PDMS? Retrospective analysis of cost and reimbursement data of a 25 bed Intensive Care Unit at a German University Hospital, three years before (2004-2006) and three years after (2007-2009) PDMS implementation. Costs and revenues increased continuously over the years. The profit of the investigated ICU was fluctuating over the years and seemingly depending on other factors as well. We found a small increase in profit in the year after the introduction of the PDMS, but not in the following years. Profit per case peaked at 1039 € in 2007, but dropped subsequently to 639 € per case. We found no clear evidence for cost savings after the PDMS introduction. Our cautious calculation did not consider additional labour costs for IT staff needed for system maintenance. The introduction of a PDMS has probably minimal or no effect on reimbursement. In our case the observed increase in profit was too small to amortize the total investment for PDMS implementation.This may add some counterweight to the literature, where expectations for tools such as the PDMS can be quite unreasonable.

Safe swallowing and communicating for ventilated intensive care patients with tracheostoma: implementation of the Passy Muir speaking valve

PubMed

Fröhlich, Martin R; Boksberger, Heidi; Barfuss-Schneider, Claudia; Liem, Esther; Petry, Heidi

2017-01-01

Background: Between 4 to 45 % of intensive care patients suffer from prolonged ventilator dependence. Due to impeded weaning, verbal communication is impossible. The tracheal cannula affects breathing and swallowing. The Passy Muir speaking valve (PMV) allows patients on ventilators to speak. It counteracts pharyngeal as well as laryngeal desensitization and prevents an insufficient swallowing reflex. Aim and methods: To implement the PMV, we conducted a multiprofessional practice- and quality development project. The objective was to ensure safe swallowing and communicating for ventilated patients with tracheostoma. Results: Intensive care nurses, doctors and physiotherapists assessed patient safety as being high. In nine patients with 51 PMV applications, we observed three undesirable events in terms of dyspnea and oxygen desaturation. On one occasion, it was necessary to remove the PMV. Conclusion: A combination of mandatory training for the entire treatment team, presence of two professionals during PMV application, and a newly developed guiding document resulted in a high level of patient safety. By means of PMV, ventilated intensive care patients are able to communicate verbally and to swallow better. Complications can be identified early and solved effectively.

Use of Narrative Nursing Records for Nursing Research

PubMed Central

Park, Hyeoun-Ae; Cho, InSook; Ahn, Hee-Jung

2012-01-01

To explore the usefulness of narrative nursing records documented using a standardized terminology-based electronic nursing records system, we conducted three different studies on (1) the gaps between the required nursing care time and the actual nursing care time, (2) the practice variations in pressure ulcer care, and (3) the surveillance of adverse drug events. The narrative nursing notes, documented at the point of care using standardized nursing statements, were extracted from the clinical data repository at a teaching hospital in Korea and analyzed. Our findings were: the pediatric and geriatric units showed relatively high staffing needs; overall incidence rate of pressure ulcer among the intensive-care patients was 15.0% and the nursing interventions provided for pressure-ulcer care varied depending on nursing units; and at least one adverse drug event was noted in 53.0% of the cancer patients who were treated with cisplatin. A standardized nursing terminology-based electronic nursing record system allowed us to explore answers to different various research questions. PMID:24199111

[Algorithms for early mobilization in intensive care units].

PubMed

Nydahl, P; Dubb, R; Filipovic, S; Hermes, C; Jüttner, F; Kaltwasser, A; Klarmann, S; Mende, H; Nessizius, S; Rottensteiner, C

2017-03-01

Immobility of patients in intensive care units (ICU) can lead to long-lasting physical and cognitive decline. During the last few years, bundles for rehabilitation were developed, including early mobilization. The German guideline for positioning therapy and mobilization, in general, recommends the development of ICU-specific protocols. The aim of this narrative review is to provide guidance when developing a best practice protocol in one's own field of work. It is recommended to a) implement early mobilization as part of a bundle, including screening and management of patient's awareness, pain, anxiety, stress, delirium and family's presence, b) develop a traffic-light system of specific in- and exclusion criteria in an interprofessional process, c) use checklists to assess risks and preparation of mobilization, d) use the ICU Mobility Scale for targeting and documentation of mobilization, e) use relative safety criteria for hemodynamic and respiratory changes, and Borg Scale for subjective evaluation, f) document and evaluate systematically mobilization levels, barriers, unwanted safety events and other parameters.

The Speaker Gender Gap at Critical Care Conferences.

PubMed

Mehta, Sangeeta; Rose, Louise; Cook, Deborah; Herridge, Margaret; Owais, Sawayra; Metaxa, Victoria

2018-06-01

To review women's participation as faculty at five critical care conferences over 7 years. Retrospective analysis of five scientific programs to identify the proportion of females and each speaker's profession based on conference conveners, program documents, or internet research. Three international (European Society of Intensive Care Medicine, International Symposium on Intensive Care and Emergency Medicine, Society of Critical Care Medicine) and two national (Critical Care Canada Forum, U.K. Intensive Care Society State of the Art Meeting) annual critical care conferences held between 2010 and 2016. Female faculty speakers. None. Male speakers outnumbered female speakers at all five conferences, in all 7 years. Overall, women represented 5-31% of speakers, and female physicians represented 5-26% of speakers. Nursing and allied health professional faculty represented 0-25% of speakers; in general, more than 50% of allied health professionals were women. Over the 7 years, Society of Critical Care Medicine had the highest representation of female (27% overall) and nursing/allied health professional (16-25%) speakers; notably, male physicians substantially outnumbered female physicians in all years (62-70% vs 10-19%, respectively). Women's representation on conference program committees ranged from 0% to 40%, with Society of Critical Care Medicine having the highest representation of women (26-40%). The female proportions of speakers, physician speakers, and program committee members increased significantly over time at the Society of Critical Care Medicine and U.K. Intensive Care Society State of the Art Meeting conferences (p < 0.05), but there was no temporal change at the other three conferences. There is a speaker gender gap at critical care conferences, with male faculty outnumbering female faculty. This gap is more marked among physician speakers than those speakers representing nursing and allied health professionals. Several organizational strategies can address this gender gap.

Role of analgesics, sedatives, neuromuscular blockers, and delirium.

PubMed

Hall, Jesse B; Schweickert, William; Kress, John P

2009-10-01

A major focus on critical care medicine concerns the institution of life-support therapies, such as mechanical ventilation, during periods of organ failure to permit a window of opportunity to diagnose and treat underlying disorders so that patients may be returned to their prior functional status upon recovery. With the growing success of these intensive care unit-based therapies and longer-term follow-up of patients, severe weakness involving the peripheral nervous system and muscles has been identified in many recovering patients, often confounding the time course or magnitude of recovery. Mechanical ventilation is often accompanied by pharmacologic treatments including analgesics, sedatives, and neuromuscular blockers. These drugs and the encephalopathies accompanying some forms of critical illness result in a high prevalence of delirium in mechanically ventilated patients. These drug effects likely contribute to an impaired ability to assess the magnitude of intensive care unit-acquired weakness, to additional time spent immobilized and mechanically ventilated, and to additional weakness from the patient's relative immobility and bedridden state. This review surveys recent literature documenting these relationships and identifying approaches to minimize pharmacologic contributions to intensive care unit-acquired weakness.

The effect of nursing participation in the design of a critical care information system: a case study in a Chinese hospital.

PubMed

Qin, Yanhong; Zhou, Ranyun; Wu, Qiong; Huang, Xiaodi; Chen, Xinli; Wang, Weiwei; Wang, Xun; Xu, Hua; Zheng, Jing; Qian, Siyu; Bai, Changqing; Yu, Ping

2017-12-06

Intensive care information systems (ICIS) are continuously evolving to meet the ever changing information needs of intensive care units (ICUs), providing the backbone for a safe, intelligent and efficient patient care environment. Although beneficial for the international advancement in building smart environments to transform ICU services, knowledge about the contemporary development of ICIS worldwide, their usage and impacts is limited. This study aimed to fill this knowledge gap by researching the development and implementation of an ICIS in a Chinese hospital, nurses' use of the system, and the impact of system use on critical care nursing processes and outcomes. This descriptive case study was conducted in a 14-bed Respiratory ICU in a tertiary hospital in Beijing. Participative design was the method used for ICU nurses, hospital IT department and a software company to collaboratively research and develop the ICIS. Focus group discussions were conducted to understand the subjective perceptions of the nurses toward the ICIS. Nursing documentation time and quality were compared before and after system implementation. ICU nursing performance was extracted from the annual nursing performance data collected by the hospital. A participative design process was followed by the nurses in the ICU, the hospital IT staff and the software engineers in the company to develop and implement a highly useful ICIS. Nursing documentation was fully digitized and was significantly improved in quality and efficiency. The wrong data, missing data items and calculation errors were significantly reduced. Nurses spent more time on direct patient care after the introduction of the ICIS. The accuracy and efficiency of medication administration was also improved. The outcome was improvement in ward nursing performance as measured by ward management, routine nursing practices, disinfection and isolation, infection rate and mortality rate. Nurses in this ICU unit in China actively participated in the ICIS development and fully used the system to document care. Introduction of the ICIS led to significant improvement in quality and efficiency in nursing documentation, medication order transcription and administration. It allowed nurses to spend more time with patients to improve quality of care. These led to improvement in overall nursing performance. Further study should investigate how the ICIS system contributes to the improvement in decision making of ICU nurses and intensivists.

Voluntary peer review as innovative tool for quality improvement in the intensive care unit – a retrospective descriptive cohort study in German intensive care units

PubMed Central

Kumpf, Oliver; Bloos, Frank; Bause, Hanswerner; Brinkmann, Alexander; Deja, Maria; Marx, Gernot; Kaltwasser, Arnold; Dubb, Rolf; Muhl, Elke; Greim, Clemens-A.; Weiler, Norbert; Chop, Ines; Jonitz, Günther; Schaefer, Henning; Felsenstein, Matthias; Liebeskind, Ursula; Leffmann, Carsten; Jungbluth, Annemarie; Waydhas, Christian; Pronovost, Peter; Spies, Claudia; Braun, Jan-Peter

2014-01-01

Introduction: Quality improvement and safety in intensive care are rapidly evolving topics. However, there is no gold standard for assessing quality improvement in intensive care medicine yet. In 2007 a pilot project in German intensive care units (ICUs) started using voluntary peer reviews as an innovative tool for quality assessment and improvement. We describe the method of voluntary peer review and assessed its feasibility by evaluating anonymized peer review reports and analysed the thematic clusters highlighted in these reports. Methods: Retrospective data analysis from 22 anonymous reports of peer reviews. All ICUs – representing over 300 patient beds – had undergone voluntary peer review. Data were retrieved from reports of peers of the review teams and representatives of visited ICUs. Data were analysed with regard to number of topics addressed and results of assessment questionnaires. Reports of strengths, weaknesses, opportunities and threats (SWOT reports) of these ICUs are presented. Results: External assessment of structure, process and outcome indicators revealed high percentages of adherence to predefined quality goals. In the SWOT reports 11 main thematic clusters were identified representative for common ICUs. 58.1% of mentioned topics covered personnel issues, team and communication issues as well as organisation and treatment standards. The most mentioned weaknesses were observed in the issues documentation/reporting, hygiene and ethics. We identified several unique patterns regarding quality in the ICU of which long-term personnel problems und lack of good reporting methods were most interesting Conclusion: Voluntary peer review could be established as a feasible and valuable tool for quality improvement. Peer reports addressed common areas of interest in intensive care medicine in more detail compared to other methods like measurement of quality indicators. PMID:25587245

Voluntary peer review as innovative tool for quality improvement in the intensive care unit--a retrospective descriptive cohort study in German intensive care units.

PubMed

Kumpf, Oliver; Bloos, Frank; Bause, Hanswerner; Brinkmann, Alexander; Deja, Maria; Marx, Gernot; Kaltwasser, Arnold; Dubb, Rolf; Muhl, Elke; Greim, Clemens-A; Weiler, Norbert; Chop, Ines; Jonitz, Günther; Schaefer, Henning; Felsenstein, Matthias; Liebeskind, Ursula; Leffmann, Carsten; Jungbluth, Annemarie; Waydhas, Christian; Pronovost, Peter; Spies, Claudia; Braun, Jan-Peter

2014-01-01

Quality improvement and safety in intensive care are rapidly evolving topics. However, there is no gold standard for assessing quality improvement in intensive care medicine yet. In 2007 a pilot project in German intensive care units (ICUs) started using voluntary peer reviews as an innovative tool for quality assessment and improvement. We describe the method of voluntary peer review and assessed its feasibility by evaluating anonymized peer review reports and analysed the thematic clusters highlighted in these reports. Retrospective data analysis from 22 anonymous reports of peer reviews. All ICUs - representing over 300 patient beds - had undergone voluntary peer review. Data were retrieved from reports of peers of the review teams and representatives of visited ICUs. Data were analysed with regard to number of topics addressed and results of assessment questionnaires. Reports of strengths, weaknesses, opportunities and threats (SWOT reports) of these ICUs are presented. External assessment of structure, process and outcome indicators revealed high percentages of adherence to predefined quality goals. In the SWOT reports 11 main thematic clusters were identified representative for common ICUs. 58.1% of mentioned topics covered personnel issues, team and communication issues as well as organisation and treatment standards. The most mentioned weaknesses were observed in the issues documentation/reporting, hygiene and ethics. We identified several unique patterns regarding quality in the ICU of which long-term personnel problems und lack of good reporting methods were most interesting Conclusion: Voluntary peer review could be established as a feasible and valuable tool for quality improvement. Peer reports addressed common areas of interest in intensive care medicine in more detail compared to other methods like measurement of quality indicators.

A case study evaluation of a Critical Care Information System adoption using the socio-technical and fit approach.

PubMed

Yusof, Maryati Mohd

2015-07-01

Clinical information systems have long been used in intensive care units but reports on their adoption and benefits are limited. This study evaluated a Critical Care Information System implementation. A case study summative evaluation was conducted, employing observation, interview, and document analysis in operating theatres and 16-bed adult intensive care units in a 400-bed Malaysian tertiary referral centre from the perspectives of users (nurses and physicians), management, and information technology staff. System implementation, factors influencing adoption, fit between these factors, and the impact of the Critical Care Information System were evaluated after eight months of operation. Positive influences on system adoption were associated with technical factors, including system ease of use, usefulness, and information relevancy; human factors, particularly user attitude; and organisational factors, namely clinical process-technology alignment and champions. Organisational factors such as planning, project management, training, technology support, turnover rate, clinical workload, and communication were barriers to system implementation and use. Recommendations to improve the current system problems were discussed. Most nursing staff positively perceived the system's reduction of documentation and data access time, giving them more time with patients. System acceptance varied among doctors. System use also had positive impacts on timesaving, data quality, and clinical workflow. Critical Care Information Systems is crucial and has great potentials in enhancing and delivering critical care. However, the case study findings showed that the system faced complex challenges and was underutilised despite its potential. The role of socio-technical factors and their fit in realizing the potential of Critical Care Information Systems requires continuous, in-depth evaluation and stakeholder understanding and acknowledgement. The comprehensive and specific evaluation measures of the Human-Organisation-Technology Fit framework can flexibly evaluate Critical Care Information Systems. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Montenegro in the PISA Study

ERIC Educational Resources Information Center

Milic, Saša

2011-01-01

Montenegro, a country that has been in transition for the last two decades, is trying intensively to restructure its socioeconomic system and reform the main social systems, such as the education system, health care, the judicial system, the social welfare system, etc. Numerous strategic documents have been adopted in the past decade emphasising…

Satisfaction with care and decision making among parents/caregivers in the pediatric intensive care unit: a comparison between English-speaking whites and Latinos.

PubMed

Epstein, David; Unger, Jennifer B; Ornelas, Beatriz; Chang, Jennifer C; Markovitz, Barry P; Dodek, Peter M; Heyland, Daren K; Gold, Jeffrey I

2015-04-01

Because of previously documented health care disparities, we hypothesized that English-speaking Latino parents/caregivers would be less satisfied with care and decision making than English-speaking non-Latino white (NLW) parents/caregivers. An intensive care unit (ICU) family satisfaction survey, Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version), was completed by English-speaking parents/caregivers of children in a cardiothoracic ICU at a university-affiliated children's hospital in 2011. English-speaking NLW and Latino parents/caregivers of patients, younger than 18 years, admitted to the ICU were approached to participate on hospital day 3 or 4 if they were at the bedside for greater than or equal to 2 days. Analysis of variance, χ(2), and Student t tests were used. Cronbach αs were calculated. Fifty parents/caregivers completed the survey in each group. Latino parents/caregivers were younger, more often mothers born outside the United States, more likely to have government insurance or no insurance, and had less education and income. There were no differences between the groups' mean overall satisfaction scores (92.6 ± 8.3 and 93.0 ± 7.1, respectively; P = .80). The Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version) showed high internal consistency reliability (α = .95 and .91 for NLW and Latino groups, respectively). No disparities in ICU satisfaction with care and decision making between English-speaking NLW and Latino parents/caregivers were found. Copyright © 2014 Elsevier Inc. All rights reserved.

Patient's dignity in intensive care unit: A critical ethnography.

PubMed

Bidabadi, Farimah Shirani; Yazdannik, Ahmadreza; Zargham-Boroujeni, Ali

2017-01-01

Maintaining patient's dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units. The aim of this study was to uncover the cultural factors that impeded maintaining patients' dignity in the cardiac surgery intensive care unit. The study was conducted using a critical ethnographic method proposed by Carspecken. Participants and research context: Participants included all physicians, nurses and staffs working in the study setting (two cardiac surgery intensive care units). Data collection methods included participant observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace. Ethical Consideration: Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained. The findings of the study fell into the following main themes: "Presence: the guarantee for giving enough attention to patients' self-esteem", "Instrumental and objectified attitudes", "Adherence to the human equality principle: value-action gap", "Paternalistic conduct", "Improper language", and "Non-interactive communication". The final assertion was "Reductionism as a major barrier to the maintaining of patient's dignity". The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches. Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships.

The positive financial impact of using an Intensive Care Information System in a tertiary Intensive Care Unit.

PubMed

Levesque, Eric; Hoti, Emir; de La Serna, Sofia; Habouchi, Houssam; Ichai, Philippe; Saliba, Faouzi; Samuel, Didier; Azoulay, Daniel

2013-03-01

In the French healthcare system, the intensive care budget allocated is directly dependent on the activity level of the center. To evaluate this activity level, it is necessary to code the medical diagnoses and procedures performed on Intensive Care Unit (ICU) patients. The aim of this study was to evaluate the effects of using an Intensive Care Information System (ICIS) on the incidence of coding errors and its impact on the ICU budget allocated. Since 2005, the documentation on and monitoring of every patient admitted to our ICU has been carried out using an ICIS. However, the coding process was performed manually until 2008. This study focused on two periods: the period of manual coding (year 2007) and the period of computerized coding (year 2008) which covered a total of 1403 ICU patients. The time spent on the coding process, the rate of coding errors (defined as patients missed/not coded or wrongly identified as undergoing major procedure/s) and the financial impact were evaluated for these two periods. With computerized coding, the time per admission decreased significantly (from 6.8 ± 2.8 min in 2007 to 3.6 ± 1.9 min in 2008, p<0.001). Similarly, a reduction in coding errors was observed (7.9% vs. 2.2%, p<0.001). This decrease in coding errors resulted in a reduced difference between the potential and real ICU financial supplements obtained in the respective years (€194,139 loss in 2007 vs. a €1628 loss in 2008). Using specific computer programs improves the intensive process of manual coding by shortening the time required as well as reducing errors, which in turn positively impacts the ICU budget allocation. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Assessment of a prototype for the Systemization of Nursing Care on a mobile device.

PubMed

Rezende, Laura Cristhiane Mendonça; Santos, Sérgio Ribeiro Dos; Medeiros, Ana Lúcia

2016-01-01

assess a prototype for use on mobile devices that permits registering data for the Systemization of Nursing Care at a Neonatal Intensive Care Unit. an exploratory and descriptive study was undertaken, characterized as an applied methodological research, developed at a teaching hospital. the mobile technology the nurses at the Neonatal Intensive Care Unit use was positive, although some reported they faced difficulties to manage it, while others with experience in using mobile devices did not face problems to use it. The application has the functions needed for the Systematization of Nursing Care at the unit, but changes were suggested in the interface of the screens, some data collection terms and parameters the application offers. The main contributions of the software were: agility in the development and documentation of the systemization, freedom to move, standardization of infant assessment, optimization of time to develop bureaucratic activities, possibilities to recover information and reduction of physical space the registers occupy. prototype software for the Systemization of Nursing Care with mobile technology permits flexibility for the nurses to register their activities, as the data can be collected at the bedside.

The Ethics of Rationing of Critical Care Services: Should Technology Assessment Play a Role?

PubMed Central

Bloomfield, Eric L.

2009-01-01

The costs of health care continue to increase rapidly and steeply in the United States. One area of great expense is that of intensive care units (ICUs). The causes of inflation have not been addressed effectively. ICU resources could become stretched such that they may no longer be available. This paper discusses some of the ethics and concerns behind decision making when providing ICU services in the United States. In particular, the use of electronic records with decision making tools, risk-analysis methods, and documentation of patient wishes for extraordinary care may help with better utilization of resources in the future. PMID:20798878

[Development, implementation, and analysis of a "collaborative decision-making for reasonable care" document in pediatric palliative care].

PubMed

Paoletti, M; Litnhouvongs, M-N; Tandonnet, J

2015-05-01

In France, a legal framework and guidelines state that decisions to limit treatments (DLT) require a collaborative decision meeting and a transcription of decisions in the patient's file. The do-not-attempt-resuscitation order involves the same decision-making process for children in palliative care. To fulfill the law's requirements and encourage communication within the teams, the Resource Team in Pediatric Palliative Care in Aquitaine created a document shared by all children's hospital units, tracing the decision-making process. This study analyzed the decision-making process, quality of information transmission, and most particularly the relevance of this new "collaborative decision-making for reasonable care" card. Retrospective study evaluating the implementation of a traceable document relating the DLT process. All the data sheets collected between January and December 2013 were analyzed. A total of 58 data sheets were completed between January and December 2013. We chose to collect the most relevant data to evaluate the relevance of the items to be completed and the transmission of the document, to draw up the patients' profile, and the contents of discussions with families. Of the 58 children for whom DLT was discussed, 41 data sheets were drawn up in the pediatric intensive care unit, seven in the oncology and hematology unit, five in the neonatology unit, four in the neurology unit, and one in the pneumology unit. For 30 children, one sheet was created, for 11 children, two sheets and for two children, three sheets were filled out. Thirty-nine decisions were made for withholding lifesaving treatment, 11 withdrawing treatment, and for five children, no limitation was set. Nine children survived after DLT. Of the 58 data sheets, only 31 discussions with families were related to the content of the data sheet. Of the 14 children transferred out of the unit with a completed data sheet, it was transmitted to the new unit for 11 children (79%). The number of data sheets collected in 1 year shows the value of this document. The participation of several pediatric specialities' referents in its creation, then its progressive presentation in the children's hospital units, were essential steps in introducing and establishing its use. Items describing the situation, management proposals, and adaptation of the children's supportive care were completed in the majority of cases. They correspond to a clinical description, the object of the discussion, and the daily caregiver's practices, respectively. On the other hand, discussions with families were related to the card's contents in only 53% of the cases. This can be explained by the time required to complete the DLT process. It is difficult for referring doctors to systematically, faithfully, and objectively transcribe discussions with parents. Although this process has been used for a long time in intensive care units, this document made possible an indispensable formalisation in the decision-making process. In other pediatric specialities, the sheet allowed introducing the palliative approach and was a starter and a tool for reflection on the do-not-attempt-resuscitation order, thus suggesting the need for anticipation in these situations. With the implementation of this new document, the DLT, data transmission, and continuity of care conditions were improved in the children's hospital units. Sharing this sheet with all professionals in charge of these children would support homogeneity and quality of management and care for children and their parents. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Sleep and adverse environmental factors in sedated mechanically ventilated pediatric intensive care patients.

PubMed

Al-Samsam, Rim H; Cullen, Pauline

2005-09-01

To document the quantity and architecture of sleep using objective electrophysiologic assessment in sedated mechanically ventilated pediatric intensive care unit patients over a 24-hr period and to investigate the effect of noise and staff interventions on sleep pattern in these subjects. Prospective observational study. Pediatric intensive care unit at a university hospital. A total of 11 patients studied between September 2000 and June 2001, with ages ranging from 3 to 21 months. All patients were intubated, mechanically ventilated, and sedated with morphine and midazolam infusions. Limited sleep polysomnograph, staff interventions, and noise levels were continuously monitored during a 24-hr period. Noise levels were consistently >48 dB(A); the highest night peak reached 103 dB(A). Staff interventions lasted for a mean of 240 (SD 90) mins in a 24-hr period. There was no significant difference in the number of interventions between day and night. Severe alterations to sleep architecture were found throughout the 24 hrs, with no diurnal variations. Active sleep was severely reduced to a mean of 3% (SD 4%; range, 0-11%) of total sleep time. There was severe sleep fragmentation as reflected by the high number (mean, 40 [SD 20]) of wake episodes. The above findings suggest a significant electrophysiologic abnormality of sleep in the pediatric intensive care unit patients. Our pediatric intensive care unit environment is characterized by both, high noise levels and frequent staff interventions. This study has several limitations and future studies are needed, with larger sample size and an attempt to manipulate the environmental factors to minimize their negative effects on sleep.

[Management of patients under 18years of age by adult intensive care unit professionals: Level of training, workload, and specific challenges].

PubMed

Brossier, D; Villedieu, F; Letouzé, N; Pinto Da Costa, N; Jokic, M

2017-03-01

In routine practice, intensive care physicians rarely have to manage children under 18years of age, particularly those under 15. This study's objectives were to assess the quality of training in pediatrics of adult intensive care teams, to document the workload generated by care of pediatric patients, and to identify the difficulties encountered in managing minors as patients. A survey was administered in Lower Normandy from 4 April 2012 to 1 September 2012. Physicians, residents, nurses, and nurses' aides practicing in one of the nine intensive care units of Lower Normandy were asked to complete an electronic or paper format questionnaire. This questionnaire assessed their level of pediatric training, the workload management of pediatric patients entailed, and the challenges posed by these patients. One hundred and nine questionnaires were returned (by 26 attending physicians, 18 residents, 38 nurses, and 27 nurses' aides). Eighty-three of the respondents (76%) had no experience in a pediatric unit of any kind. Forty-two percent thought that the pediatric age range lies between 3months and 15years of age. However, more than 50% of respondents would like the upper limit to be 16years or even older. Ninety-three respondents (85%) estimated having some exposure to pediatric patients in their routine practice, but this activity remained quite low. Seventy-three (67%) reported difficulties with the management of these young patients. This survey provides current information regarding the level of training of adult intensive care unit professionals and their concerns about managing patients under 18years of age, both in terms of workload and specific challenges. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

[Can implementation of intensified perinatal survey be effective in improving the quality of perinatal care?].

PubMed

Troszyński, Michał

2010-01-01

Intensive scientific research and rapid technical progress have influenced the rapid fall in term newborn mortality. At the same time new problems have arisen such as saving the lives of infants with low and very low birth weight. Solving these problems needs reorganization of perinatal care, better equipment, especially in reference units and in outpatient clinics, as well as more intensive staff training. to obtain information whether implementation of intensified perinatal survey of fetus and newborn mortality can improve the quality of perinatal care in Poland. Implementation of the survey based on Central Statistics Office (GUS) data, Ministry of Health MZ-29 section X Document and the author's own studies. In the year 2008 newborn with birth weight less than 2500 g, constituted 6,06% liveborn infants, newborn weighing from 1000 to 2499 g - 5%, those with weight from 500 to 999 g - 0.51% of all live born infants. These figures differ according to voivodeship. The intensive survey concerning birth weight and perinatal mortality indeces in voivodeshipPoland, as well as in individual voivodeships, showed differences between data from the Central Statistics Office and data from the Ministry of Health MZ-29 document. This may be due to different methods of registrating newborn deaths eg. newborns transfered in the first weekoflife from the maternity ward to intensive care neonatal ward or to other specialistic departaments. Another reason for the difference may be discharge of the newborn data according to the place of birth or the mother's place of permanent domicile registration. This causes disturbances in flow of infomation resulting in ineffective analysis of perinatal mortality and of perinatal care evaluation. In the ongoing analysis it was found that in Poland stillbirths occur twice as often as perinatal deaths (4.3 per thousands) stillbirths and 2.15 per thousands perinatal deaths), with significant differences between voivodeships. This makes it obligatory to conduct medical audit which is a form of specialistic supervision. It is probable that higher number of stillbirths and premature births may be caused by late start of perinatal care in pregnancy. In primary health care, insufficient objective parameters are investigated which lead to assessment of the quality of perinatal care. Correct filling up of the pregnancy chart could improve the quality of the management of prophylactic procedures leading to a fall in the number of premature births and stillbirths. This would also lead to a reduction of costs associated with life saving procedures and improving the quality of life in newborns with low and extremly low birth weight. 1. The survey of fetal and newborn perinatal mortality of fetuses and newborn should be the base for elaborating the perinatal care programme as well as the main source of data for medical audit. This is the instrument for evaluation of the three level perinatal care. It also serves to assess the effectivness of diagnostic and therapeutic recommendations and the programme of active prevention. 2. In order to obtain effectivness in functioning of the three step perinatal care within the framework of the National Health Programme the following steps are needed: - urgent elaboration of new or improved medical documentation which will become obligatory, - implementation of educational programmes and training of teachers. 3. Implementation of medical audit, carried out periodically at all three levels of perinatal care.

[Analysis of the web pages of the intensive care units of Spain].

PubMed

Navarro-Arnedo, J M

2009-01-01

In order to determine the Intensive Care Units (ICU) of Spanish hospitals that had a web site, to analyze the information they offered and to know what information they needed to offer according to a sample of ICU nurses, a cross-sectional observational, descriptive study was carried out between January and September 2008. For each ICU website, an analysis was made on the information available on the unit, its care, teaching and research activity on nursing. Simultaneously, based on a sample of intensive care nurses, the information that should be contained on an ICU website was determined. The results, expressed in absolute numbers and percentage, showed that 66 of the 292 hospitals with ICU (22.6%) had a web site; 50.7% of the sites showed the number of beds, 19.7% the activity report, 11.3% the published articles/studies and followed research lines and 9.9% the organized formation courses. 14 webs (19.7%) displayed images of nurses. However, only 1 (1.4%) offered guides on the actions followed. No web site offered a navigation section for nursing, the E-mail of the chief nursing, the nursing documentation used or if any nursing model of their own was used. It is concluded that only one-fourth of the Spanish hospitals with ICU have a web site; number of beds was the data offered by the most sites, whereas information on care, educational and investigating activities was very reduced and that on nursing was practically omitted on the web pages of intensive care units.

End-of-life decisions in Dutch neonatal intensive care units.

PubMed

Verhagen, A A Eduard; Dorscheidt, Jozef H H M; Engels, Bernadette; Hubben, Joep H; Sauer, Pieter J

2009-10-01

To clarify the practice of end-of-life decision making in severely ill newborns. Retrospective descriptive study with face-to-face interviews. The 10 neonatal intensive care units in the Netherlands from October 2005 to September 2006. All 367 newborn infants who died in the first 2 months of life in Dutch neonatal intensive care units. Adequate documentation was available in 359 deaths. Presence of end-of-life decisions, classification of deaths in 3 groups, and physicians' considerations leading to end-of-life decisions. An end-of-life decision preceded death in 95% of cases, and in 5% treatment was continued until death. Of all of the deaths, 58% were classified as having no chance of survival and 42% were stabilized newborns with poor prognoses. Withdrawal of life-sustaining therapy was the main mode of death in both groups. One case of deliberate ending of life was found. In 92% of newborns with poor prognoses, end-of-life decisions were based on patients' future quality of life and mainly concerned future suffering. Considerations regarding the infant's present state were made in 44% of infants. Virtually all deaths in Dutch neonatal intensive care units are preceded by the decision to withdraw life-sustaining treatment and many decisions are based on future quality of life. The decision to deliberately end the life of a newborn may occur less frequently than was previously assumed.

Clinicians’ Perceptions of the Usefulness of a Communication Facilitator in the Intensive Care Unit

PubMed Central

Howell, Abby; Nielsen, Elizabeth L.; Turner, Anne M.; Curtis, J. Randall; Engelberg, Ruth A.

2015-01-01

Background Despite its documented importance, communication between clinicians and patients’ families in the intensive care unit often fails to meet families’ needs, and interventions to improve communication are needed. Use of a communication facilitator—an additional staff member—to improve communication between clinicians and patients’ families is the focus of an ongoing randomized trial. The clinical team’s acceptance of the communication facilitator as an integral part of the team is important. Objectives To explore clinicians’ perceptions of the usefulness of a communication facilitator in the intensive care unit. Methods Fourteen semistructured qualitative interviews to assess perspectives of physicians, nurses, and social workers who had experience with the communication facilitator intervention on the intervention and the role of the facilitator. Methods based on grounded theory were used to analyze the data. Results Clinicians’ perceived facilitators as (1) facilitating communication between patients’ families and clinicians, (2) providing practical and emotional support for patients’ families, and (3) providing practical and emotional support for clinicians. Clinicians were enthusiastic about the communication facilitator but concerned about overlapping or conflicting roles. Conclusions Clinicians in the intensive care unit saw the facilitator intervention as enhancing communication and supporting both patients’ families and clinicians. They also identified the importance of the facilitator within the interdisciplinary team. Negative perceptions about the use of a facilitator should be addressed before the intervention is implemented, in order to ensure its effectiveness. PMID:25179033

Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units

PubMed Central

Cai, Xuemei; Robinson, Jennifer; Muehlschlegel, Susanne; White, Douglas B.; Holloway, Robert G.; Sheth, Kevin N.; Fraenkel, Liana; Hwang, David Y.

2016-01-01

In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients. PMID:25990137

[Treatment of the child and adolescent with type 1 diabetes: special paediatric diabetes units].

PubMed

Hermoso López, F; Barrio Castellanos, R; Garcia Cuartero, B; Gómez Gila, A; González Casado, I; Oyarzabal Irigoyen, M; Rica Etxebarria, I; Rodríguez-Rigual, M; Torres Lacruz, M

2013-05-01

Intensive treatment of type 1 diabetes mellitus (DM1) delays and slows down the progression of chronic diabetes complications (DCCT 1993). This type of treatment in children and adolescents with DM1 has a different complexity to other stages of life and therefore, needs specialized care units. Various documents and declarations of diabetic patient's rights are evaluated, and the need for an adequate health care is emphasized. In the last decade, several projects have been developed in Europe to create a benchmark treatment of pediatric diabetes, with the aim of establishing hospitals with highly qualified healthcare to control it. The Diabetes Working Group of the Spanish Society for Pediatric Endocrinology (SEEP) has prepared this document in order to obtain a national consensus for the care of children and adolescents with type 1 diabetes in specialist Pediatric Diabetes Units, and at the same time advise Health Care Administrators to establish a national healthcare network for children and adolescents with diabetes mellitus, and organize comprehensive pediatric diabetes care units in hospitals with a reference level in quality of care. Copyright © 2012 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.

Acute Respiratory Failure Induced by Magnesium Replacement in a 62-Year-Old Woman with Myasthenia Gravis.

PubMed

Singh, Paramveer; Idowu, Olakunle; Malik, Imrana; Nates, Joseph L

2015-10-01

Magnesium is known to act at the neuromuscular junction by inhibiting the presynaptic release of acetylcholine and desensitizing the postsynaptic membrane. Because of these effects, magnesium has been postulated to potentiate neuromuscular weakness. We describe the case of a 62-year-old woman with myasthenia gravis and a metastatic thymoma who was admitted to our intensive care unit for management of a myasthenic crisis. The patient's neuromuscular weakness worsened in association with standard intravenous magnesium replacement, and the exacerbated respiratory failure necessitated intubation, mechanical ventilation, and an extended stay in the intensive care unit. The effect of magnesium replacement on myasthenia gravis patients has not been well documented, and we present this case to increase awareness and stimulate research. In addition, we discuss the relevant medical literature.

Assessment of a prototype for the Systemization of Nursing Care on a mobile device 1

PubMed Central

Rezende, Laura Cristhiane Mendonça; dos Santos, Sérgio Ribeiro; Medeiros, Ana Lúcia

2016-01-01

Abstract Objectives: assess a prototype for use on mobile devices that permits registering data for the Systemization of Nursing Care at a Neonatal Intensive Care Unit. Method: an exploratory and descriptive study was undertaken, characterized as an applied methodological research, developed at a teaching hospital. Results: the mobile technology the nurses at the Neonatal Intensive Care Unit use was positive, although some reported they faced difficulties to manage it, while others with experience in using mobile devices did not face problems to use it. The application has the functions needed for the Systematization of Nursing Care at the unit, but changes were suggested in the interface of the screens, some data collection terms and parameters the application offers. The main contributions of the software were: agility in the development and documentation of the systemization, freedom to move, standardization of infant assessment, optimization of time to develop bureaucratic activities, possibilities to recover information and reduction of physical space the registers occupy. Conclusion: prototype software for the Systemization of Nursing Care with mobile technology permits flexibility for the nurses to register their activities, as the data can be collected at the bedside. PMID:27384467

Congenital malformations, palliative care and postnatal redirection to more intensive treatment - a review at a Swiss tertiary center.

PubMed

Pfeifer, Ulrich; Gubler, Deborah; Bergstraesser, Eva; Bassler, Dirk

2018-05-01

The so-called lethal malformations pose ethical challenges. Most affected fetuses die before or at birth. Live-born neonates commonly receive palliative care. If the postnatal course is better than expected, redirection towards more treatment may occur. We aimed to analyze this in a Swiss patient cohort. Over 6 years, fetal malformation was suspected in 1113 cases. We identified patients prenatally assigned to palliative care, assessed pre- and postnatal diagnoses, and outcomes. Fourteen neonates received palliative care. Eleven patients received palliative care following late termination of pregnancy, for three, palliative care was planned and the fetus died during delivery, for two, the outcome was unknown (incomplete documentation). Genetic testing was performed in 50%. The predominant diagnostic group was central nervous system malformations (33%), followed by chromosomal aberrations (20%) and renal anomalies (17%). One child assigned to palliative care was resuscitated. Antenatal findings were anhydramnios and pulmonary hypoplasia. Postnatally, respiration was better than expected. The neonate was admitted to intensive care, died on day one. Nervous system malformations seem to be a major criterion for foregoing life-sustaining interventions. Redirection towards more treatment is rare. This may reflect precise prenatal prognostication; a degree of self-fulfilling prophecy cannot be excluded.

Long-term persistence of quality improvements for an intensive care unit communication initiative using the VALUE strategy.

PubMed

Wysham, Nicholas G; Mularski, Richard A; Schmidt, David M; Nord, Shirley C; Louis, Deborah L; Shuster, Elizabeth; Curtis, J Randall; Mosen, David M

2014-06-01

Communication in the intensive care unit (ICU) is an important component of quality ICU care. In this report, we evaluate the long-term effects of a quality improvement (QI) initiative, based on the VALUE communication strategy, designed to improve communication with family members of critically ill patients. We implemented a multifaceted intervention to improve communication in the ICU and measured processes of care. Quality improvement components included posted VALUE placards, templated progress note inclusive of communication documentation, and a daily rounding checklist prompt. We evaluated care for all patients cared for by the intensivists during three separate 3 week periods, pre, post, and 3 years following the initial intervention. Care delivery was assessed in 38 patients and their families in the pre-intervention sample, 27 in the post-intervention period, and 41 in follow-up. Process measures of communication showed improvement across the evaluation periods, for example, daily updates increased from pre 62% to post 76% to current 84% of opportunities. Our evaluation of this quality improvement project suggests persistence and continued improvements in the delivery of measured aspects of ICU family communication. Maintenance with point-of-care-tools may account for some of the persistence and continued improvements. Copyright © 2014 Elsevier Inc. All rights reserved.

No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations

PubMed Central

Hantel, Andrew; Wroblewski, Kristen; Balachandran, Jay S.; Chow, Selina; DeBoer, Rebecca; Fleming, Gini F.; Hahn, Olwen M.; Kline, Justin; Liu, Hongtao; Patel, Bhakti K.; Verma, Anshu; Witt, Leah J.; Fukui, Mayumi; Kumar, Aditi; Howell, Michael D.; Polite, Blase N.

2016-01-01

Purpose: Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs. Methods: This was a retrospective case series of patients cared for in an academic medical center’s ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient’s electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations. Results: Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05). Conclusion: Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care. PMID:27601514

Measuring the quality of therapeutic apheresis care in the pediatric intensive care unit.

PubMed

Sussmane, Jeffrey B; Torbati, Dan; Gitlow, Howard S

2012-01-01

Our goal was to measure the quality of care provided in the Pediatric Intensive Care Unit (PICU) during Therapeutic Apheresis (TA). We described the care as a step by step process. We designed a flow chart to carefully document each step of the process. We then defined each step with a unique clinical indictor (CI) that represented the exact task we felt provided quality care. These CIs were studied and modified for 1 year. We measured our performance in this process by the number of times we accomplished the CI vs. the total number of CIs that were to be performed. The degree of compliance, with these clinical indicators, was analyzed and used as a metric for quality by calculating how close the process is running exactly as planned or "in control." The Apheresis Process was in control (compliance) for 47% of the indicators, as measured in the aggregate for the first observational year. We then applied the theory of Total Quality Management (TQM) through our Design, Measure, Analyze, Improve, and Control (DMAIC) model. We were able to improve the process and bring it into control by increasing the compliance to > 99.74%, in the aggregate, for the third and fourth quarter of the second year. We have implemented TQM to increase compliance, thus control, of a highly complex and multidisciplinary Pediatric Intensive Care therapy. We have shown a reproducible and scalable measure of quality for a complex clinical process in the PICU, without additional capital expenditure. Copyright © 2011 Wiley-Liss, Inc.

Implementing family communication pathway in neurosurgical patients in an intensive care unit.

PubMed

Kodali, Sashikanth; Stametz, Rebecca; Clarke, Deserae; Bengier, Amanda; Sun, Haiyan; Layon, A J; Darer, Jonathan

2015-08-01

Family-centered care provides family members with basic needs, which includes information, reassurance, and support. Though national guidelines exist, clinical adoption often lags behind in this area. The Geisinger Health System developed and implemented a program for reliable delivery of best practices related to family communication to patients and families admitted to the intensive care unit (ICU). Using a quasiexperimental study design and the 24-item Family Satisfaction in the Intensive Care Unit questionnaire (FSICU-24©) to determine family satisfaction, we measured the impact of a "family communication pathway" facilitated by tools built into the electronic health record on the family satisfaction of neurosurgical patients admitted to the ICU. There was no statistically significant difference noted in family satisfaction as determined by FSICU-24 scores, including the Care and Decision Making constructs between the pre- and post-intervention pilot population. The percentage of families reporting the occurrence of a family conference showed only minimal improvement, from 46.5% before to 52.5% following the intervention (p = 0.565). This was mirrored by low numbers of documented family conferences by providers, suggesting poor uptake despite buy-in, use of electronic checklists, and repeated attempts at education. This paper reviews the challenges to and implications for implementing national guidelines in the area of family communication in an ICU coupled with the principles of clinical reengineering.

Jeffrey Baldwin: A Thematic Analysis of Media Coverage and Implications for Social Work Practice

ERIC Educational Resources Information Center

Choate, Peter W.

2017-01-01

Jeffery Baldwin died in 2002 in the care of his maternal grandparents. The case received intense media attention at various times over an almost eight-year period. Along with other public documents, the media coverage permits an analysis of the practice errors by Child Protection Services that are related to the failure to protect Jeffrey. Nine…

Detailed Analysis of Misconceptions as a Basis for Developing Remedial Instruction: The Case of Photosynthesis.

ERIC Educational Resources Information Center

Amir, Ruth; Tamir, Pinchas

A great number of misconceptions in diverse subject areas as well as across age levels have been documented and described. Photosynthesis is one of the more intensively studied areas in biology. The purpose of this research was to carefully select and define misconceptions about photosynthesis needing remedial efforts. To achieve this, a specially…

[Control of intubator associated pneumonia in intensive care unit: results of the GISIO-SItI SPIN-UTI Project].

PubMed

Agodi, Antonella; Auxilia, Francesco; Barchitta, Martina; D'Errico, Marcello Mario; Montagna, Maria Teresa; Pasquarella, Cesira; Tardivo, Stefano; Mura, Ida

2014-01-01

To document reported Intubator Associated Pneumonia (IAP) prevention practices in Intensive Care Units (ICUs) and attitudes towards the implementation of a measurement system. In the framework of the SPIN-UTI project the «Italian Nosocomial Infections Surveillance in ICUs network», two questionnaires were made available online. The first was filled out by physicians working in ICUs in order to collect data on characteristics of physicians and ICUs, on clinical and measurement practices for IAP prevention, and attitudes towards the implementation of a measurement system. The second questionnaire was filled out for each intubated patient in order to collect data on prevention practices during ICU stay. ICUs participating to the fourth edition (2012-2013) of the SPIN-UTI project. Compliance to the component of the European bundle. The components of the bundle for the prevention of IAP are implemented, although to a different level, in the 26 participating ICUs. Overall compliance to all five practices of the European bundle has been reported in 21.1% of the 768 included patients. The present survey has documented a large potential for improvement in clinical and non-clinical practices aimed at preventing IAP in ICUs.

Summary of Information and Resources Related to Energy Use in Healthcare Facilities - Version 1

DOE Office of Scientific and Technical Information (OSTI.GOV)

Singer, Brett C.; Coughlin, Jennifer L.; Mathew, Paul A.

This document presents the results of a review of publicly available information on energy use in health care facilities. The information contained in this document and in the sources cited herein provides the background and context for efforts to reduce energy use and costs in health care. Recognizing the breadth and diversity of relevant information, the author acknowledges that the report is likely not comprehensive. It is intended only to present a broad picture of what is currently known about health care energy use. This review was conducted as part of a 'High Performance Health Care Buildings' research study fundedmore » by the California Energy Commission. The study was motivated by the recognition that health care facilities collectively account for a substantial fraction of total commercial building energy use, due in large part to the very high energy intensity of hospitals and other inpatient care facilities. The goal of the study was to develop a roadmap of research, development and deployment (RD&D) needs for the health care industry. In addition to this information review, the road map development process included interviews with industry experts and a full-day workshop at LBNL in March 2009. This report is described as 'Version 1' with the intent that it will be expanded and updated as part of an ongoing LBNL program in healthcare energy efficiency. The document is being released in this form with the hope that it can assist others in finding and accessing the resources described within.« less

[Spanish translation and validation of the EMPATHIC-30 questionnaire to measure parental satisfaction in intensive care units].

PubMed

Pilar Orive, Francisco Javier; Basabe Lozano, Jasone; López Zuñiga, Aurora; López Fernández, Yolanda M; Escudero Argaluza, Julene; Latour, Jos M

2017-11-03

Few validated surveys measuring parental satisfaction in the Paediatric Intensive Care Unit (PICU) are available, and none of them in Spanish language. The aim of this study is to translate and validate the questionnaire EMpowerment of PArents in THe Intensive Care (EMPATHIC). This questionnaire measures parental perceptions of paediatric intensive care-related satisfaction items in the Spanish language. A prospective cohort study was carried out using questionnaires completed by relatives of children (range 0-17 years old) admitted into a tertiary PICU. Inclusion criteria were a length of stay more than 24h, and a suitable understanding of Spanish language by parents or guardians. Exclusion criteria were re-admissions and deceased patients. The questionnaire was translated from English to Spanish language using a standardised procedure, after which it was used in a cross-sectional observational study was performed to confirm its validity and consistency. Reliability was estimated using Cronbach's α, and content validity using Spearman's correlation analysis. A total of 150 questionnaires were collected. A Cronbach's α was obtained for domains greater than 0.7, showing a high internal consistency from the questionnaire. Validity was measured by correlating 5 domains with 4 general satisfaction items, documenting an adequate correlation (Rs: 0.41-0.66, P<.05). The Spanish version of EMPHATIC 30 is a feasible, easy, and suitable tool in this specific environment, based on the results. EMPATHIC 30 is able to measure parental satisfaction, and may serve as a valid indicator to measure quality of care in Spanish PICUs. Copyright © 2017. Publicado por Elsevier España, S.L.U.

Pulmonary thromboembolic disease. Clinical management of acute and chronic disease.

PubMed

Torbicki, Adam

2010-07-01

Pulmonary thromboembolism falls between the areas of pulmonology and cardiology, internal medicine and intensive care, radiology and nuclear medicine, and hematology and cardiothoracic surgery. Depending on their clinical background, physicians faced with a patient with a pulmonary thromboembolism may speak different languages and adopt different treatment approaches. Now, however, there is an opportunity to end the Tower of Babel surrounding pulmonary thromboembolism. There is a growing acknowledgement that the key clinical problems in both acute pulmonary embolism and chronic thromboembolic pulmonary hypertension are linked to right ventricular pressure overload and right ventricular failure. As a result, cardiologists and cardiac intensive care specialists are taking an increasing interest in understanding and combating these conditions. The European Society of Cardiology was the first to elaborate comprehensive clinical practice guidelines for pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension. The task forces involved in producing these guidelines included radiologists, pulmonologists, hematologists, intensive care physicians and surgeons, which ensured that the final document was universally acceptable. The aim of this article was to provide an overview of the epidemiology, risk factors, diagnosis, treatment, prognosis and prevention of acute pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension, while taking into account European Society of Cardiology guidelines and incorporating new evidence where necessary.

Treatment and follow-up of venous thrombosis in the neonatal intensive care unit: A retrospective study

PubMed Central

Bohnhoff, James C.; DiSilvio, Stefanie A.; Aneja, Rajesh K.; Shenk, Jennifer R.; Domnina, Yuliya A.; Brozanski, Beverly S.; Good, Misty

2016-01-01

Objective The critically ill, premature patients of neonatal intensive care units are susceptible to venous thrombosis, an adverse event associated with short- and long-term morbidity. Venous thrombosis is frequently treated with low molecular weight heparins (LMWH) such as enoxaparin, but optimal dosing of LMWH must balance the morbidity of venous thrombosis with the potential adverse affects of anticoagulation. The optimal dosing of enoxaparin for premature infants is unclear. The objective of this study was to describe enoxaparin therapy and follow-up in critically ill neonates diagnosed with venous thrombosis. Study Design Retrospective medical record review in the neonatal intensive care unit (NICU) in a single tertiary care institution. Infants with venous thrombosis diagnosed in the NICU were identified using pre-existing quality improvement lists and medical records. Results Twenty-six infants with 30 venous thromboses were identified with a median gestational age of 31 weeks at birth. Eighteen (69%) infants received enoxaparin for venous thrombosis during their hospitalization, beginning with a median dose of 1.5 mg/kg every 12h. This dose was increased to a median 2.1 mg/kg every 12h to achieve target anti-factor Xa levels. The target dose was significantly higher in patients with a postmenstrual age less than 37 weeks. Enoxaparin treatment was documented after discharge in 12 patients, continuing for a median of 99 days. Four patients died during hospitalization and their deaths were not attributable to venous thrombosis or anticoagulation complication. Follow-up documentation between 6 and 24 months after venous thrombosis diagnosis revealed no major morbidity of venous thrombosis or enoxaparin therapy. Conclusions Our data reinforces the relative safety and necessity of enoxaparin doses above 1.5 mg/kg per 12 hours in most neonates. This was particularly true for infants at lower postmenstrual age. PMID:27906197

Interprofessional Team's Perception of Care Delivery After Implementation of a Pediatric Pain and Sedation Protocol.

PubMed

Staveski, Sandra L; Wu, May; Tesoro, Tiffany M; Roth, Stephen J; Cisco, Michael J

2017-06-01

Pain and agitation are common experiences of patients in pediatric cardiac intensive care units. Variability in assessments by health care providers, communication, and treatment of pain and agitation creates challenges in management of pain and sedation. To develop guidelines for assessment and treatment of pain, agitation, and delirium in the pediatric cardiac intensive unit in an academic children's hospital and to document the effects of implementation of the guidelines on the interprofessional team's perception of care delivery and team function. Before and after implementation of the guidelines, interprofessional team members were surveyed about the members' perception of analgesia, sedation, and delirium management RESULTS: Members of the interprofessional team felt more comfortable with pain and sedation management after implementation of the guidelines. Team members reported improvements in team communication on patients' comfort. Members thought that important information was less likely to be lost during transfer of care. They also noted that the team carried out comfort management plans and used pharmacological and nonpharmacological therapies better after implementation of the guidelines than they did before implementation. Guidelines for pain and sedation management were associated with perceived improvements in team function and patient care by members of the interprofessional team. ©2017 American Association of Critical-Care Nurses.

Impact of depression on the intensity of patient navigation for women with abnormal cancer screenings.

PubMed

De La Cruz, Ignacio I; Freund, Karen M; Battaglia, Tracy A; Chen, Clara A; Bak, Sharon; Kalish, Richard; Lottero, Barbara; Egan, Patrick; Heeren, Tim; Kronman, Andrea C

2014-02-01

Patient navigation is increasingly being used to support vulnerable patients to receive timely and quality medical care. We sought to understand whether patients with depression utilize additional patient navigation services after abnormal cancer screening. We compared depressed and non-depressed women using three different measures of intensity of patient navigation: number of patient-navigator encounters, encounter time, and number of unique barriers to care. The study population consisted of 1,455 women who received navigation after abnormal screening for breast or cervical cancer at one of six community health centers in Boston. Navigators spent a median of 60-75 minutes over one or two encounters per participant, with 49% of participants having one or more documented barrier to care. Depressed women did not differ in total numbers of encounters, encounter time, or unique barriers compared with non-depressed women. Our findings suggest that pre-existing depression does not predict which women will utilize additional navigation services.

Sleep in the Intensive Care Unit

PubMed Central

Friese, Randall S.; Gehlbach, Brian K.; Schwab, Richard J.; Weinhouse, Gerald L.; Jones, Shirley F.

2015-01-01

Sleep is an important physiologic process, and lack of sleep is associated with a host of adverse outcomes. Basic and clinical research has documented the important role circadian rhythm plays in biologic function. Critical illness is a time of extreme vulnerability for patients, and the important role sleep may play in recovery for intensive care unit (ICU) patients is just beginning to be explored. This concise clinical review focuses on the current state of research examining sleep in critical illness. We discuss sleep and circadian rhythm abnormalities that occur in ICU patients and the challenges to measuring alterations in circadian rhythm in critical illness and review methods to measure sleep in the ICU, including polysomnography, actigraphy, and questionnaires. We discuss data on the impact of potentially modifiable disruptors to patient sleep, such as noise, light, and patient care activities, and report on potential methods to improve sleep in the setting of critical illness. Finally, we review the latest literature on sleep disturbances that persist or develop after critical illness. PMID:25594808

A Systematic Review of Family Meeting Tools in Palliative and Intensive Care Settings

PubMed Central

Singer, Adam E.; Ash, Tayla; Ochotorena, Claudia; Lorenz, Karl A.; Chong, Kelly; Shreve, Scott T.; Ahluwalia, Sangeeta C.

2015-01-01

Purpose Family meetings can be challenging, requiring a range of skills and participation. We sought to identify tools available to aid the conduct of family meetings in palliative, hospice, and intensive care unit settings. Methods We systematically reviewed PubMed for articles describing family meeting tools and abstracted information on tool type, usage, and content. Results We identified 16 articles containing 23 tools in 7 categories: meeting guide (n = 8), meeting planner (n = 5), documentation template (n = 4), meeting strategies (n = 2), decision aid/screener (n = 2), family checklist (n = 1), and training module (n = 1). We found considerable variation across tools in usage and content and a lack of tools supporting family engagement. Conclusion There is need to standardize family meeting tools and develop tools to help family members effectively engage in the process. PMID:26213225

A Systematic Review of Family Meeting Tools in Palliative and Intensive Care Settings.

PubMed

Singer, Adam E; Ash, Tayla; Ochotorena, Claudia; Lorenz, Karl A; Chong, Kelly; Shreve, Scott T; Ahluwalia, Sangeeta C

2016-09-01

Family meetings can be challenging, requiring a range of skills and participation. We sought to identify tools available to aid the conduct of family meetings in palliative, hospice, and intensive care unit settings. We systematically reviewed PubMed for articles describing family meeting tools and abstracted information on tool type, usage, and content. We identified 16 articles containing 23 tools in 7 categories: meeting guide (n = 8), meeting planner (n = 5), documentation template (n = 4), meeting strategies (n = 2), decision aid/screener (n = 2), family checklist (n = 1), and training module (n = 1). We found considerable variation across tools in usage and content and a lack of tools supporting family engagement. There is need to standardize family meeting tools and develop tools to help family members effectively engage in the process. © The Author(s) 2015.

Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit

PubMed Central

Palma, JP; Sharek, PJ; Longhurst, CA

2016-01-01

Objective To evaluate the impact of integrating a handoff tool into the electronic medical record (EMR) on sign-out accuracy, satisfaction and workflow in a neonatal intensive care unit (NICU). Study Design Prospective surveys of neonatal care providers in an academic children’s hospital 1 month before and 6 months following EMR integration of a standalone Microsoft Access neonatal handoff tool. Result Providers perceived sign-out information to be somewhat or very accurate at a rate of 78% with the standalone handoff tool and 91% with the EMR-integrated tool (P < 0.01). Before integration of neonatal sign-out into the EMR, 35% of providers were satisfied with the process of updating sign-out information and 71% were satisfied with the printed sign-out document; following EMR integration, 92% of providers were satisfied with the process of updating sign-out information (P < 0.01) and 98% were satisfied with the printed sign-out document (P < 0.01). Neonatal care providers reported spending a median of 11 to 15 min/day updating the standalone sign-out and 16 to 20 min/day updating the EMR-integrated sign-out (P = 0.026). The median percentage of total sign-out preparation time dedicated to transcribing information from the EMR was 25 to 49% before and <25% after EMR integration of the handoff tool (P < 0.01). Conclusion Integration of a NICU-specific handoff tool into an EMR resulted in improvements in perceived sign-out accuracy, provider satisfaction and at least one aspect of workflow. PMID:21273990

Perianal Dermatitis, Its Incidence, and Patterns of Topical Therapies in a Level IV Neonatal Intensive Care Unit.

PubMed

Malik, Anuj; Witsberger, Emily; Cottrell, Lesley; Kiefer, Autumn; Yossuck, Panitan

2018-04-01

 To define the incidence of perianal dermatitis (PD) and determine the usage pattern and cost efficacy of diaper products among neonates admitted to a level IV neonatal intensive care unit (NICU) including those with a diagnosis of neonatal abstinence syndrome (NAS).  A retrospective cohort study to evaluate neonates with PD based on number of orders for Aquaphor, Bagbalm, Desitin, Flanders, or Nystatin. Various demographic and clinical parameters were recorded. Usage patterns of these five products were analyzed, and their costs estimated. Subgroup analysis was performed among infants with NAS.  Of 1,241 admissions, 56.2% had at least one diaper product ordered during their NICU stay, while 52.6% had multiple products ordered. Only 23.0% of all neonates had appropriate documentation of PD. The most common product ordered first was Aquaphor (64.3%), followed by Desitin (19.2%). Note that 86% term NAS infants had PD compared with 28% term non-NAS infants. The estimated product cost was $14,139 over 2 years, averaging $20 per patient.  Over half of NICU neonates were exposed to one or more diaper products, usually without documented PD diagnosis. Term NAS infants had three times higher incidence of PD than term non-NAS infants. The cost of diaper product use was significant, and possibly underestimated due to lack of documentation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Case Study: A Guide to Working with a Language Impaired Child.

ERIC Educational Resources Information Center

Sapir, Selma G.; Rainho, Sergio

The document presents the case study of the interaction of a graduate student in traning, her supervisor, an 8 year old child with a language learning problem, and the child's mother. It involves a process which entails the careful matching of the child to tutor, the tutor to supervisor, and intensive work with the mother. It also is based on what…

The effect of point-of-care personal digital assistant use on resident documentation discrepancies.

PubMed

Carroll, Aaron E; Tarczy-Hornoch, Peter; O'Reilly, Eamon; Christakis, Dimitri A

2004-03-01

We recently found documentation discrepancies in 60% of resident daily-progress notes with respect to patient weight, medications, or vascular lines. To what extent information systems can decrease such discrepancies is unknown. To determine whether a point-of-care personal digital assistant (PDA)-based patient record and charting system could reduce the number of resident progress-note documentation discrepancies in a neonatal intensive care unit (NICU). We conducted a before-and-after trial in an academic NICU. Our intervention was a PDA-based patient record and charting system used by all NICU resident physicians over the study period. We analyzed all resident daily-progress notes from 40 randomly selected days over 4 months in both the baseline and intervention periods. Using predefined reference standards, we determined the accuracy of recorded information for patient weights, medications, and vascular lines. Logistic and Poisson regression were used in analyses to control for potential confounding factors. A total of 339 progress notes in the baseline period and 432 progress notes in the intervention period were reviewed. When controlling for covariates in the regression, there were significantly fewer documentation discrepancies of patient weights in notes written by using the PDA system (14.4%-4.4% of notes; odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.15-0.56). When using the PDA system, there were no significant changes in the numbers of notes with documentation discrepancies of medications (27.7%-17.1% of notes; OR: 0.63; 95% CI: 0.35-1.13) or vascular lines (33.6%-36.1% of notes; OR: 1.11; 95% CI: 0.66-1.87). The use of our PDA-based point-of-care patient record and charting system showed a modest benefit in reducing the number of documentation discrepancies in resident daily-progress notes. Further study of PDAs in information systems is warranted before they are widely adopted.

The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient care by staff in the ICU: a review of the literature.

PubMed

Mador, Rebecca L; Shaw, Nicola T

2009-07-01

The introduction of a Critical Care Information System (CCIS) into an intensive care unit (ICU) is purported to reduce the time health care providers (HCP) spend on documentation and increase the time available for direct patient care. However, there is a paucity of rigorous empirical research that has investigated these assertions. Moreover, those studies that have sought to elucidate the relationship between the introduction of a CCIS and the time spent by staff on in/direct patient care activities have published contradictory findings. The objective of this literature review is to establish the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU. Five electronic databases were searched including PubMed Central, EMBASE, CINAHL, IEEE Xplore, and the Cochrane Database of Systematic Reviews. Reference lists of all published papers were hand searched, and citations reviewed to identify extra papers. We included studies that were empirical articles, published in English, and provided original data on the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU. In total, 12 articles met the inclusion criteria. Workflow analysis (66%) and time-and-motion analysis (25%) were the most common forms of data collection. Three (25%) studies found an increase in time spent charting, five (42%) found no difference, and four (33%) studies reported a decrease. Results on the impact of a CCIS on direct patient care were similarly inconclusive. Due to the discrepant findings and several key methodological issues, the impact of a CCIS on time spent charting and in direct patient care remains unclear. This review highlights the need for an increase in rigorous empirical research in this area and provides recommendations for the design and implementation of future studies.

Pressure Injury Prevention in a Saudi Arabian Intensive Care Unit: Registered Nurse Attitudes Toward Prevention Strategies and Perceived Facilitators and Barriers to Evidence Implementation.

PubMed

Tayyib, Nahla; Coyer, Fiona; Lewis, Peter

2016-01-01

The purpose of this study was to examine RNs' attitudes toward pressure injury (PI) prevention strategies. Barriers and facilitators perceived by RNs to potentially impact on the adoption and implementation of PI prevention interventions in the intensive care unit (ICU) were examined. Descriptive cross-sectional survey. The target population was RNs practicing in an intensive care unit (ICU) of a major tertiary hospital, King Abdul-Aziz, Mecca, in Saudi Arabia. Fifty-six of the available 60 ICU RNs participated in this study. Data were collected via survey using the Attitude towards Pressure injury Prevention instrument, which included 13 items rated with 4-point Likert scale, and the modified Barriers and Facilitators tool, which included 27 items. The survey was organized into 3 parts: demographic information, potential barriers to optimal skin care, and potential facilitators to skin care. The survey took 10 to 15 minutes to complete. Data were analyzed with descriptive-correlation statistics and multiple regression analysis. Thematic analysis was undertaken for qualitative data. Participants demonstrated positive attitudes toward PI prevention (μ = 38.19/52; 73.44%). No significant differences were found between demographic characteristics of the participants with the RNs' Attitude subscale and perceived barriers and facilitators associated with implementing PI prevention in the critical care setting. Several barriers influenced the ability of RNs to implement PI prevention strategies including time demands (β = .388; P = .011), limitation of RNs' knowledge (β = -.632; P = .022), and current documentation format (β = .344; P = .046). Statistically significant facilitating factors that increased respondents ability to undertake PI prevention were ease of obtaining pressure-reduction surfaces (β = -.388; P = .007), collaboration with interdisciplinary teams (β = .37; P = .02), and availability of appropriate skin care products (β = .44; P = .015). Thematic analysis of open-ended questions highlighted workload as a barrier that impedes the implementation of care specific to PI prevention. Findings from this study highlighted that ICU RNs had a positive attitude toward PI prevention. This study also identified perceived factors influencing PI prevention in the ICU, both facilitators and barriers. Perceived facilitators included availability of pressure-relieving support surfaces and appropriate skin care products and collaboration with the healthcare professional team. However, perceived barriers included limited PI prevention knowledge of the nurse and RN workflow (time demands and documentation format). Findings from this study provide important information identifying context-specific factors that may influence the adoption and implementation of PI prevention interventions in the ICU.

Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units

PubMed Central

Domanico, R; Davis, D K; Coleman, F; Davis, B O

2011-01-01

Objective: To test the efficacy of single family room (SFR) neonatal intensive care unit (NICU) designs, questions regarding patient medical progress and relative patient safety were explored. Addressing these questions would be of value to hospital staff, administrators and designers alike. Study Design: This prospective study documented, by means of Institution Review Board-approved protocols, the progress of patients in two contrasting NICU designs. Noise levels, illumination and air quality measurements were included to define the two NICU physical environments. Result: Infants in the SFR unit had fewer apneic events, reduced nosocomial sepsis and mortality, as well as earlier transitions to enteral nutrition. More mothers sustained stage III lactation, and more infants were discharged breastfeeding in the SFR. Conclusion: This study showed the SFR to be more conducive to family-centered care, and to enhance infant medical progress and breastfeeding success over that of an open ward. PMID:21072040

Educating fellows in practice-based learning and improvement and systems-based practice: The value of quality improvement in clinical practice.

PubMed

Carey, William A; Colby, Christopher E

2013-02-01

In 1999, the Accreditation Council for Graduate Medical Education identified 6 general competencies in which all residents must receive training. In the decade since these requirements went into effect, practice-based learning and improvement (PBLI) and systems-based practice (SBP) have proven to be the most challenging competencies to teach and assess. Because PBLI and SBP both are related to quality improvement (QI) principles and processes, we developed a QI-based curriculum to teach these competencies to our fellows. This experiential curriculum engaged our fellows in our neonatal intensive care unit's (NICU's) structured QI process. After identifying specific patient outcomes in need of improvement, our fellows applied validated QI methods to develop evidence-based treatment protocols for our neonatal intensive care unit. These projects led to immediate and meaningful improvements in patient care and also afforded our fellows various means by which to demonstrate their competence in PBLI and SBP. Our use of portfolios enabled us to document our fellows' performance in these competencies quite easily and comprehensively. Given the clinical and educational structures common to most intensive care unit-based training programs, we believe that a QI-based curriculum such as ours could be adapted by others to teach and assess PBLI and SBP. Copyright © 2013 Elsevier Inc. All rights reserved.

Critical care medicine in the hospital: lessons from the EURICUS-studies.

PubMed

Miranda, D Reis; Rivera-Fernández, R; Nap, R E

2007-05-01

We have performed a retrospective analysis of the EURICUS-studies using their database at the Foundation for Research on Intensive Care in Europe (FRICE) and other related documents, among which the various reports produced to the European Union which granted the studies, with the following purposes: a) to select and describe the most relevant observational and experimental results of the EURICUS studies; b) to inventory the main obstacles to the appropriate organization of intensive care medicine in the Hospital and c) to highlight amid the acquired knowledge those subjects which could have a direct and primary impact for improving the organization and management of intensive care units (ICUs). The EURICUS-studies have shown a rather non-systematic variation on the variables of the organization and management, resulting in a significant waste of resources and in a generally perceived insufficient performance of ICUs in Europe. Three major roadblocks were found: a) the lack of a clear concept of Critical Care Medicine; b) the lack of defined objectives both regarding the planning of the facilities and the activities to be developed in the ICU and c) the lack of a purposeful organization and management of work in the ICU. The further development and integration of each ICU in the Hospital should consider the following: a) the system approach to the analysis and standardization of processes of care; b) the redefinition of all jobs in each ICU; c) the definition of patient/nurse ratios in each ICU and sibling departments and d) to professionalize the organization and management of the ICU.

Changing personnel behavior to promote quality care practices in an intensive care unit

PubMed Central

Cooper, Dominic; Farmery, Keith; Johnson, Martin; Harper, Christine; Clarke, Fiona L; Holton, Phillip; Wilson, Susan; Rayson, Paul; Bence, Hugh

2005-01-01

The delivery of safe high quality patient care is a major issue in clinical settings. However, the implementation of evidence-based practice and educational interventions are not always effective at improving performance. A staff-led behavioral management process was implemented in a large single-site acute (secondary and tertiary) hospital in the North of England for 26 weeks. A quasi-experimental, repeated-measures, within-groups design was used. Measurement focused on quality care behaviors (ie, documentation, charting, hand washing). The results demonstrate the efficacy of a staff-led behavioral management approach for improving quality-care practices. Significant behavioral change (F [6, 19] = 5.37, p < 0.01) was observed. Correspondingly, statistically significant (t-test [t] = 3.49, df = 25, p < 0.01) reductions in methicillin-resistant Staphylococcus aureus (MRSA) were obtained. Discussion focuses on implementation issues. PMID:18360574

Quality of Care: A Review of Maternal Deaths in a Regional Hospital in Ghana.

PubMed

Adusi-Poku, Yaw; Antwil, Edward; Osei-Kwakye, Kingsley; Tetteh, Chris; Detoh, Eric Kwame; Antwi, Phyllis

2015-09-01

The government of Ghana and key stakeholders have put into place several interventions aimed at reducing maternal deaths. At the institutional level, the conduct of maternal deaths audit has been instituted. This also contributes to reducing maternal deaths as shortcomings that may have contributed to such deaths could be identified to inform best practice and forestall such occurrences in the future. The objective of this study was to review the quality of maternal care in a regional hospital. A review of maternal deaths using Quality of Care Evaluation Form adapted from the Komfo Anokye Teaching Hospital (KATH) Maternal Death Audit Evaluation Committee was used. About fifty-five percent, 18 (55%) of cases were deemed to have received adequate documentation, senior clinicians were involved in 26(85%) of cases. Poor documentation, non-involvement of senior clinicians in the management of cases, laboratory related issues particularly in relation to blood and blood products as well as promptness of care and adequacy of intensive care facilities and specialists in the hospital were contributory factors to maternal deaths . These are common themes contributing to maternal deaths in developing countries which need to be urgently tackled. Maternal death review with emphasis on quality of care, coupled with facility gap assessment, is a useful tool to address the adequacy of emergency obstetric care services to prevent further maternal deaths.

The culture of patient safety in an Iranian intensive care unit.

PubMed

Abdi, Zhaleh; Delgoshaei, Bahram; Ravaghi, Hamid; Abbasi, Mohsen; Heyrani, Ali

2015-04-01

To explore nurses' and physicians' attitudes and perceptions relevant to safety culture and to elicit strategies to promote safety culture in an intensive care unit. A strong safety culture is essential to ensure patient safety in the intensive care unit. This case study adopted a mixed method design. The Safety Attitude Questionnaire (SAQ-ICU version), assessing the safety climate through six domains, was completed by nurses and physicians (n = 42) in an academic intensive care unit. Twenty semi-structured interviews and document analyses were conducted as well. Interviews were analysed using a framework analysis method. Mean scores across the six domains ranged from 52.3 to 72.4 on a 100-point scale. Further analysis indicated that there were statistically significant differences between physicians' and nurses' attitudes toward teamwork (mean scores: 64.5/100 vs. 52.6/100, d = 1.15, t = 3.69, P < 0.001) and job satisfaction (mean scores: 78.2/100 vs. 57.7/100, d = 1.5, t = 4.8, P < 0.001). Interviews revealed several safety challenges including underreporting, failure to learn from errors, lack of speaking up, low job satisfaction among nurses and ineffective nurse-physician communication. The results indicate that all the domains need improvements. However, further attention should be devoted to error reporting and analysis, communication and teamwork among professional groups, and nurses' job satisfaction. Nurse managers can contribute to promoting a safety culture by encouraging staff to report errors, fostering learning from errors and addressing inter-professional communication problems. © 2013 John Wiley & Sons Ltd.

[Surface disinfection in the context of infection prevention in intensive care units].

PubMed

Kossow, A; Schaber, S; Kipp, F

2013-03-01

The highest proportion of nosocomial infections occurs on intensive care units (ICU) and infections with multiresistant pathogens are an ever increasing problem. Preventative measures should consist of a bundle of different measures including measures that address a specific problem and standard hygiene measures that are relevant in all areas. Specific measures in ICUs primarily aim at the prevention of ventilator associated pneumonia, blood vessel catheter associated infections and nosocomial urinary tract infections. Surface disinfection belongs to the standard hygiene measures and plays an inferior role compared to hand hygiene; however, surfaces come into focus in outbreak situations. The Commission on Hospital Hygiene (KRINKO) at the Robert Koch Institute (the German health protection agency) published recommendations regarding the cleaning and disinfection of surfaces. The frequency with which cleaning and/or disinfection is required varies according to defined areas of risk. The frequency and the disinfection agents used are documented in the disinfection plan.

[Incidence and Costs of 1:1 Care in Psychiatric Hospitals in Germany - A Descriptive Analysis Based on the VIPP Project Data Set].

PubMed

Nienaber, André; Schulz, Michael; Noelle, Rüdiger; Wiegand, Hauke Felix; Wolff-Menzler, Claus; Häfner, Sibylle; Seemüller, Florian; Godemann, Frank; Löhr, Michael

2016-05-01

1:1 care is applied for patients requiring close psychiatric monitoring and care like patients with acute suicidality. The article describes the frequency of 1:1 care across different diagnoses and age groups in German psychiatric hospitals. The analysis was based on the VIPP Project from the years 2011 and 2012. A total of 47 hospitals with more than 120,000 cases were included. Object of the analysis was the OPS code 9-640.0 1:1 care. The evaluation was performed on case level. Data of 47 hospitals were included. Of the 121,454 cases evaluated in 2011 3.8 % documented a 1:1 care within the meaning of OPS 9-640.0 additional code. Of the 66 245 male cases a 1:1 care was documented in 3.5 % and the 55 207 female cases was 4.1 %. Compared to 2011, the proportion of 1:1 care in 2012 rose to 4.8 %. The results show that 1:1 care is frequently applied in German psychiatric hospitals. The Data of the VIPP project have proven to be a useful tool to gain information on the frequency of cost-intensive interventions in German psychiatric hospitals. Further analyses should create the possibility of evaluation at the level of the individual codes. © Georg Thieme Verlag KG Stuttgart · New York.

77 FR 18963 - Energy Conservation Program: Public Meeting and Availability of the Framework Document for High...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-29

... the Framework Document for High-Intensity Discharge Lamps AGENCY: Office of Energy Efficiency and... availability of framework document for high-intensity discharge (HID) lamps, initiating the rulemaking and data... Availability of Framework Document Regarding Energy Conservation Standards for High-Intensity Discharge (HID...

Perspectives of physicians and nurses regarding end-of-life care in the intensive care unit.

PubMed

Festic, Emir; Wilson, Michael E; Gajic, Ognjen; Divertie, Gavin D; Rabatin, Jeffrey T

2012-02-01

The delivery of end-of-life care (EOLC) in the intensive care unit (ICU) varies widely among medical care providers. The differing opinions of nurses and physicians regarding EOLC may help identify areas of improvement. To explore the differences of physicians and nurses on EOLC in the ICU and how these differences vary according to self-reported proficiency level and primary work unit. Cross-sectional survey of 69 ICU physicians and 629 ICU nurses. Single tertiary care academic medical institution. A total of 50 physicians (72%) and 331 nurses (53%) participated in the survey. Significant differences between physicians and nurses were noted in the following areas: ability to safely raise concerns, do not resuscitate (DNR) decision making, discussion of health care directives, timely hospice referral, spiritual assessment documentation, utilization of social services, and the availability of EOLC education. In every domain of EOLC, physicians reported a more positive perception than nurses. Additional differences were noted among physicians based on experience, as well as among nurses based on their primary work unit and self-reported proficiency level. Even with an increased focus on improving EOLC, significant differences continue to exist between the perspectives of nurses and physicians, as well as physicians among themselves and nurses among themselves. These differences may represent significant barriers toward providing comprehensive, consistent, and coordinated EOLC in the ICU.

[Modification of nursing practice through reflection: participatory action research].

PubMed

Delgado Hito, P; Sola Prado, A; Mirabete Rodríguez, I; Torrents Ros, R; Blasco Afonso, M; Barrero Pedraza, R; Catalá Gil, N; Mateos Dávila, A; Quinteiro Canedo, M

2001-01-01

Technology and complex techniques are inevitably playing an increasing role in intensive care units. They continue to characterize nursing care and in some cases dehumanize it. The general aim of this study was to stimulate reflection on nursing care. The study was based on the participation of the investigators with the goal of producing changes in nursing practice. Qualitative methodology in the form of participatory action research and the Kemmis and McTaggart method were used. Data were collected through systematic observation, seven group meetings and document analysis. Eight nurses took part in the study. The meetings were recorded and transcribed verbatim into a computer. This process and the meaning of the verbatim transcription (codification/categorization process and document synthesis cards) were analyzed. The results of this study enabled exploration of the change in nursing practice and showed that the reflection in action method stimulates changes in practice. The new way of conceiving nursing action has increased nursing care quality and its humanization since it shows greater respect for the patient, provides families with closer contact and greater support, improves coordination of nursing care acts and increases collaboration among professionals.In conclusion, participatory action research is a valid and appropriate method that nurses can use to modify their daily practice.

Caring and technology in an intensive care unit: an ethnographic study.

PubMed

Price, Ann M

2013-11-01

Critical care practice is a mixture of caring and technological activities. There is debate about whether the balance between these two elements is correct and a concern that critical care units can dehumanize the patient. This research sought to examine aspects that might affect this balance between the caring and technology within the critical care setting. What aspects affect registered health care professionals' ability to care for patients within the technological environment of a critical care unit? A qualitative approach using ethnography was utilized as this methodology focuses on the cultural elements within a situation. Data collection involved participant observation, document review and semi-structured interviews to triangulate methods as this aids rigour for this approach. A purposeful sample to examine registered health care professionals currently working within the study area was used. A total of 19 participants took part in the study; 8 nurses were observed and 16 health care professionals were interviewed, including nurses, a doctor and 2 physiotherapists. The study took place on a District General Hospital intensive care unit and ethical approval was gained. An overarching theme of the 'Crafting process' was developed with sub themes of 'vigilance', 'focus of attention, 'being present' and 'expectations' with the ultimate goal of achieving the best interests for the individual patient. The areas reflected in this study coincide with the care, compassion, competency, commitment, communication and courage ideas detailed by the Department of Health (2012). Thus, further research to detail more specifically how these areas are measured within critical care may be useful. Caring is a complex concept that is difficult to outline but this article can inform practitioners about the aspects that help and hinder caring in the technical setting to inform training. © 2013 British Association of Critical Care Nurses.

Estimating Time Physicians and Other Health Care Workers Spend with Patients in an Intensive Care Unit Using a Sensor Network.

PubMed

Butler, Rachel; Monsalve, Mauricio; Thomas, Geb W; Herman, Ted; Segre, Alberto M; Polgreen, Philip M; Suneja, Manish

2018-04-09

Time and motion studies have been used to investigate how much time various health care professionals spend with patients as opposed to performing other tasks. However, the majority of such studies are done in outpatient settings, and rely on surveys (which are subject to recall bias) or human observers (which are subject to observation bias). Our goal was to accurately measure the time physicians, nurses, and critical support staff in a medical intensive care unit spend in direct patient contact, using a novel method that does not rely on self-report or human observers. We used a network of stationary and wearable mote-based sensors to electronically record location and contacts among health care workers and patients under their care in a 20-bed intensive care unit for a 10-day period covering both day and night shifts. Location and contact data were used to classify the type of task being performed by health care workers. For physicians, 14.73% (17.96%) of their time in the unit during the day shift (night shift) was spent in patient rooms, compared with 40.63% (30.09%) spent in the physician work room; the remaining 44.64% (51.95%) of their time was spent elsewhere. For nurses, 32.97% (32.85%) of their time on unit was spent in patient rooms, with an additional 11.34% (11.79%) spent just outside patient rooms. They spent 11.58% (13.16%) of their time at the nurses' station and 23.89% (24.34%) elsewhere in the unit. From a patient's perspective, we found that care times, defined as time with at least one health care worker of a designated type in their intensive care unit room, were distributed as follows: 13.11% (9.90%) with physicians, 86.14% (88.15%) with nurses, and 8.14% (7.52%) with critical support staff (eg, respiratory therapists, pharmacists). Physicians, nurses, and critical support staff spend very little of their time in direct patient contact in an intensive care unit setting, similar to reported observations in both outpatient and inpatient settings. Not surprisingly, nurses spend far more time with patients than physicians. Additionally, physicians spend more than twice as much time in the physician work room (where electronic medical record review and documentation occurs) than the time they spend with all of their patients combined. Copyright © 2018 Elsevier Inc. All rights reserved.

The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments.

PubMed

Sprung, Charles L; Paruk, Fathima; Kissoon, Niranjan; Hartog, Christiane S; Lipman, Jeffrey; Du, Bin; Argent, Andrew; Hodgson, R Eric; Guidet, Bertrand; Groeneveld, A B Johan; Feldman, Charles

2014-12-01

Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees. Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared. Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent. Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency. Copyright © 2014 Elsevier Inc. All rights reserved.

All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time.

PubMed

Westbrook, Johanna I; Ampt, Amanda; Kearney, Leanne; Rob, Marilyn I

2008-05-05

To quantify time doctors in hospital wards spend on specific work tasks, and with health professionals and patients. Observational time and motion study. 400-bed teaching hospital in Sydney. 19 doctors (seven registrars, five residents, seven interns) in four wards were observed between 08:30 and 19:00 for a total of 151 hours between July and December 2006. Proportions of time in categories of work; proportions of tasks performed with health professionals and patients; proportions of tasks using specific information tools; rates of multitasking and interruptions. The greatest proportions of doctors' time were in professional communication (33%; 95% CI, 29%-38%); social activities, such as non-work communication and meal breaks (17%; 95% CI, 13%-21%), and indirect care, such as planning care (17%; 95% CI, 15%-19%). Multitasking involved 20% of time, and on average, doctors were interrupted every 21 minutes. Most tasks were completed with another doctor (56%; 95% CI, 55%-57%), while 24% (95% CI, 23%-25%) were undertaken alone and 15% (95% CI, 15%-16%) with a patient. Interns spent more time completing documentation and administrative tasks, and less time in direct care than residents and registrars. The time interns spent documenting (22%) was almost double the time they were engaged in direct patient care. Two-thirds of doctors' time was consumed by three work categories: professional communication, social activities and indirect care. Doctors on wards are interrupted at considerably lower rates than those in emergency and intensive care units. The results confirm interns' previously reported dissatisfaction with their level of administrative work and documentation.

A Real-time Ventilator Management Dashboard: Toward Hardwiring Compliance with Evidence-based Guidelines

PubMed Central

Starmer, John; Giuse, Dario

2008-01-01

Care of mechanically ventilated patients requires coordination between multiple caregivers, necessitating the availability of accurate and timely information on patient status. Researchers have documented positive effects of several interventions on the rates of developing ventilator associated complications, such as providing regular oral care and elevating the head of the bed. Informatics tools, such as electronic whiteboards, reminders, and alerts have been shown to aid in clinician compliance with guidelines or protocols. The purpose of this project was to design and implement a real-time ventilator management dashboard to show patient status with respect to elements important for ventilator management and infection prevention in the adult Intensive Care Units at Vanderbilt University Medical Center. PMID:18998939

Differing perspectives on parent access to their child's electronic medical record during neonatal intensive care hospitalization: a pilot study.

PubMed

Chung, Rebecca K; Kim, Una Olivia; Basir, Mir Abdul

2018-04-01

To improve informed medical decision-making, principles for family-centered neonatal care recommend that parents have access to their child's medical record on an ongoing basis during neonatal intensive unit care (NICU) hospitalization. Currently, many NICUs do not allow independent parent access to their child's electronic medical record (EMR) during hospitalization. We undertook a cross-sectional survey pilot study of medical professionals and parents to explore opinions regarding this practice. Inclusion criteria: 18-years old, English-literate, legal guardian of patients admitted to the NICU for 14 days. NICU medical professionals included physicians, nurse practitioners, nurses, and respiratory therapists. Medical professionals believed parent access would make their work more difficult, increase time documenting and updating families, making them more liable to litigation and hesitant to chart sensitive information. However, parents felt that they lacked control over their child's care and desired direct access to the EMR. Parents believed this would improve accuracy of their child's medical chart, and increase advocacy and understanding of their child's illness. NICU parents and medical professionals have differing perspectives on independent parental access to their child's EMR. More research is needed to explore the potential of independent parental EMR access to further improve family-centered neonatal care.

Radiant energy and insensible water loss in the premature newborn infant nursed under a radiant warmer.

PubMed

Baumgart, S

1982-10-01

Radiant warmers are a powerful and efficient source of heat serving to warm the cold-stressed infant acutely and to provide uninterrupted maintenance of body temperature despite a multiplicity of nursing, medical, and surgical procedures required to care for the critically ill premature newborn in today's intensive care nursery. A recognized side-effect of radiant warmer beds is the now well-documented increase in insensible water loss through evaporation from an infant's skin. Particularly the very-low-birth-weight, severely premature, and critically ill neonate is subject to this increase in evaporative water loss. The clinician caring for the infant is faced with the difficult problem of fluid and electrolyte balance, which requires vigilant monitoring of all parameters of fluid homeostasis. Compounding these difficulties, other portions of the electromagnetic spectrum (for example, phototherapy) may affect an infant's fluid metabolism by mechanisms that are not well understood. The role of plastic heat shielding in reducing large insensible losses in infants nursed on radiant warmer beds is currently under intense investigation. Apparently, convective air currents and not radiant heat energy may be the cause of the observed increase in insensible water loss in the intensive care nursery. A thin plastic blanket may be effective in reducing evaporative water loss by diminishing an infant's exposure to convective air currents while being nursed on an open radiant warmer bed. A rigid plastic body hood, although effective as a radiant heat shield, is not as effective in preventing exposure to convection in the intensive care nursery and, therefore, is not as effective as the thin plastic blanket in reducing insensible water loss. Care should be exercised in determining the effect of heat shielding on all parameters of heat exchange (convection, evaporation, and radiation) before application is made to the critically ill premature infant nursed on an open radiant warmer bed.

Describing Intravenous Extravasation in Children (DIVE Study).

PubMed

Paquette, Vanessa; McGloin, Rumi; Northway, Tracie; Dezorzi, Pia; Singh, Avash; Carr, Roxane

2011-09-01

Extravasation, the inadvertent leakage of intravenous (IV) medication from the vein into the surrounding tissue, is a iatrogenic cause of patient injury. Extravasation has been reported to occur in 0.1% to 6.5% of hospital inpatients. The incidence may be higher among children because they have multiple risk factors, including small and fragile veins, decreased peripheral circulation, capillary leakage, and flexible subcutaneous tissue. To describe the incidence of extravasation at a pediatric tertiary care hospital, to identify the agents causing extravasation, and to describe the use of antidotes to manage identified cases. A secondary objective was to describe adverse drug effects associated with the antidotes administered. The medical records of pediatric patients with documented extravasation of an IV medication between January 1, 2006, and August 31, 2008, were analyzed retrospectively. The appropriateness of antidote use was determined in terms of adherence to the institution's protocol for treatment of extravasation. A total of 42 patients had documented extravasation, for an overall incidence of 0.04% per patient-day. Of the 40 cases in which location was documented, 12 (30%) occurred on the general pediatric wards, 10 (25%) on the surgical ward, 9 (22%) in the neonatal intensive care unit, 5 (12%) in the pediatric intensive care unit, 3 (8%) in day care, and 1 (2%) in the emergency department. The most common medications involved were fluids for IV administration (18 [43%]), potassium chloride (11 [26%]), antibiotics (8 [19%]), total parenteral nutrition (8 [19%]), calcium chloride (2 [5%]), and epinephrine (2 [5%]). Multiple drugs were involved in some cases of extravasation. The decision to administer an antidote and the choice of antidote (if required) were appropriate in 50% of the cases. No adverse drug effects were reported with use of antidotes. The incidence of extravasation was low. The medications most commonly involved were similar to those reported in the literature. Antidotes were well tolerated but were appropriately used in only half of the events. Prospective trials are needed to determine the clinical severity of injury and to assess the effectiveness and safety of antidotes.

Describing Intravenous Extravasation in Children (DIVE Study)

PubMed Central

Paquette, Vanessa; McGloin, Rumi; Northway, Tracie; DeZorzi, Pia; Singh, Avash; Carr, Roxane

2011-01-01

Background: Extravasation, the inadvertent leakage of intravenous (IV) medication from the vein into the surrounding tissue, is a iatrogenic cause of patient injury. Extravasation has been reported to occur in 0.1% to 6.5% of hospital inpatients. The incidence may be higher among children because they have multiple risk factors, including small and fragile veins, decreased peripheral circulation, capillary leakage, and flexible subcutaneous tissue. Objectives: To describe the incidence of extravasation at a pediatric tertiary care hospital, to identify the agents causing extravasation, and to describe the use of antidotes to manage identified cases. A secondary objective was to describe adverse drug effects associated with the antidotes administered. Methods: The medical records of pediatric patients with documented extravasation of an IV medication between January 1, 2006, and August 31, 2008, were analyzed retrospectively. The appropriateness of antidote use was determined in terms of adherence to the institution’s protocol for treatment of extravasation. Results: A total of 42 patients had documented extravasation, for an overall incidence of 0.04% per patient-day. Of the 40 cases in which location was documented, 12 (30%) occurred on the general pediatric wards, 10 (25%) on the surgical ward, 9 (22%) in the neonatal intensive care unit, 5 (12%) in the pediatric intensive care unit, 3 (8%) in day care, and 1 (2%) in the emergency department. The most common medications involved were fluids for IV administration (18 [43%]), potassium chloride (11 [26%]), antibiotics (8 [19%]), total parenteral nutrition (8 [19%]), calcium chloride (2 [5%]), and epinephrine (2 [5%]). Multiple drugs were involved in some cases of extravasation. The decision to administer an antidote and the choice of antidote (if required) were appropriate in 50% of the cases. No adverse drug effects were reported with use of antidotes. Conclusions: The incidence of extravasation was low. The medications most commonly involved were similar to those reported in the literature. Antidotes were well tolerated but were appropriately used in only half of the events. Prospective trials are needed to determine the clinical severity of injury and to assess the effectiveness and safety of antidotes. PMID:22479086

Developing a Comprehensive Model of Intensive Care Unit Processes: Concept of Operations.

PubMed

Romig, Mark; Tropello, Steven P; Dwyer, Cindy; Wyskiel, Rhonda M; Ravitz, Alan; Benson, John; Gropper, Michael A; Pronovost, Peter J; Sapirstein, Adam

2015-04-23

This study aimed to use a systems engineering approach to improve performance and stakeholder engagement in the intensive care unit to reduce several different patient harms. We developed a conceptual framework or concept of operations (ConOps) to analyze different types of harm that included 4 steps as follows: risk assessment, appropriate therapies, monitoring and feedback, as well as patient and family communications. This framework used a transdisciplinary approach to inventory the tasks and work flows required to eliminate 7 common types of harm experienced by patients in the intensive care unit. The inventory gathered both implicit and explicit information about how the system works or should work and converted the information into a detailed specification that clinicians could understand and use. Using the ConOps document, we created highly detailed work flow models to reduce harm and offer an example of its application to deep venous thrombosis. In the deep venous thrombosis model, we identified tasks that were synergistic across different types of harm. We will use a system of systems approach to integrate the variety of subsystems and coordinate processes across multiple types of harm to reduce the duplication of tasks. Through this process, we expect to improve efficiency and demonstrate synergistic interactions that ultimately can be applied across the spectrum of potential patient harms and patient locations. Engineering health care to be highly reliable will first require an understanding of the processes and work flows that comprise patient care. The ConOps strategy provided a framework for building complex systems to reduce patient harm.

The Determinants of Productivity in Medical Testing: Intensity and Allocation of Care*

PubMed Central

Abaluck, Jason; Agha, Leila; Kabrhel, Chris; Raja, Ali; Venkatesh, Arjun

2017-01-01

A large body of research has investigated whether physicians overuse care. There is less evidence on whether, for a fixed level of spending, doctors allocate resources to patients with the highest expected returns. We assess both sources of inefficiency exploiting variation in rates of negative imaging tests for pulmonary embolism. We document enormous across-doctor heterogeneity in testing conditional on patient population, which explains the negative relationship between physicians’ testing rates and test yields. Furthermore, doctors do not target testing to the highest risk patients, reducing test yields by one third. Our calibration suggests misallocation is more costly than overuse. PMID:29104293

Eluding Meaninglessness: A Note to Self in Regard to Camus, Critical Care, and the Absurd

PubMed Central

Papadimos, Thomas John

2014-01-01

Here I present a medical narrative, as a catharsis, regarding Albert Camus’s The Myth of Sisyphus in an attempt to elude meaninglessness in my difficult everyday practice of critical care medicine. It is well documented that physicians who practice critical care medicine are subject to burnout. The sense of despair that occasionally overwhelms me prompted my rereading of Camus’s classic text and caused me to recount his arguments that life is meaningless unless one is willing to take a leap of faith to the divine or, alternately, to commit suicide. This set up the examination of his third alternative, acceptance of a life without prima facie evidence of purpose and meaning, a view that may truly have some bearing on my professional life in the intensive care unit. PMID:24626076

The perceived quality of interprofessional teamwork in an intensive care unit: A single centre intervention study.

PubMed

Van den Bulcke, Bo; Vyt, Andre; Vanheule, Stijn; Hoste, Eric; Decruyenaere, Johan; Benoit, Dominique

2016-05-01

This article describes a study that evaluated the quality of teamwork in a surgical intensive care unit and assessed whether teamwork could be improved significantly through a tailor-made intervention. The quality of teamwork prior to and after the intervention was assessed using the Interprofessional Practice and Education Quality Scales (IPEQS) using the PROSE online diagnostics and documenting system, which assesses three domains of teamwork: organisational factors, care processes, and team members' attitudes and beliefs. Furthermore, team members evaluated strengths and weaknesses of the teamwork through open-ended questions. Information gathered by means of the open questions was used to design a tailor-made 12-week intervention consisting of (1) optimising the existing weekly interdisciplinary meetings with collaborative decision-making and clear communication of goal-oriented actions, including the psychosocial aspects of care; and (2) organising and supporting the effective exchange of information over time between all professions involved. It was found that the intervention had a significant impact on organisational factors and care processes related to interprofessional teamwork for the total group and within all subgroups, despite baseline differences between the subgroups in interprofessional teamwork. In conclusion, teamwork, and more particularly the organisational aspects of interprofessional collaboration and processes of care, can be improved by a tailor-made intervention that takes into account the professional needs of healthcare workers.

Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team.

PubMed

Curtis, J Randall; Cook, Deborah J; Wall, Richard J; Angus, Derek C; Bion, Julian; Kacmarek, Robert; Kane-Gill, Sandra L; Kirchhoff, Karin T; Levy, Mitchell; Mitchell, Pamela H; Moreno, Rui; Pronovost, Peter; Puntillo, Kathleen

2006-01-01

Quality improvement is an important activity for all members of the interdisciplinary critical care team. Although an increasing number of resources are available to guide clinicians, quality improvement activities can be overwhelming. Therefore, the Society of Critical Care Medicine charged this Outcomes Task Force with creating a "how-to" guide that focuses on critical care, summarizes key concepts, and outlines a practical approach to the development, implementation, evaluation, and maintenance of an interdisciplinary quality improvement program in the intensive care unit. The task force met in person twice and by conference call twice to write this document. We also conducted a literature search on "quality improvement" and "critical care or intensive care" and searched online for additional resources. DATA SYNTHESIS AND OVERVIEW: We present an overview of quality improvement in the intensive care unit setting and then describe the following steps for initiating or improving an interdisciplinary critical care quality improvement program: a) identify local motivation, support teamwork, and develop strong leadership; b) prioritize potential projects and choose the first target; c) operationalize the measures, build support for the project, and develop a business plan; d) perform an environmental scan to better understand the problem, potential barriers, opportunities, and resources for the project; e) create a data collection system that accurately measures baseline performance and future improvements; f) create a data reporting system that allows clinicians and others to understand the problem; g) introduce effective strategies to change clinician behavior. In addition, we identify four steps for evaluating and maintaining this program: a) determine whether the target is changing with periodic data collection; b) modify behavior change strategies to improve or sustain improvements; c) focus on interdisciplinary collaboration; and d) develop and sustain support from the hospital leadership. We also identify a number of online resources to complement this overview. This Society of Critical Care Medicine Task Force report provides an overview for clinicians interested in developing or improving a quality improvement program using a step-wise approach. Success depends not only on committed interdisciplinary work that is incremental and continuous but also on strong leadership. Further research is needed to refine the methods and identify the most cost-effective means of improving the quality of health care received by critically ill patients and their families.

Streamlining the medication process improves safety in the intensive care unit.

PubMed

Benoit, E; Eckert, P; Theytaz, C; Joris-Frasseren, M; Faouzi, M; Beney, J

2012-09-01

Multiple interventions were made to optimize the medication process in our intensive care unit (ICU). 1 Transcriptions from the medical order form to the administration plan were eliminated by merging both into a single document; 2 the new form was built in a logical sequence and was highly structured to promote completeness and standardization of information; 3 frequently used drug names, approved units, and fixed routes were pre-printed; 4 physicians and nurses were trained with regard to the correct use of the new form. This study was aimed at evaluating the impact of these interventions on clinically significant types of medication errors. Eight types of medication errors were measured by a prospective chart review before and after the interventions in the ICU of a public tertiary care hospital. We used an interrupted time-series design to control the secular trends. Over 85 days, 9298 lines of drug prescription and/or administration to 294 patients, corresponding to 754 patient-days were collected and analysed for the three series before and three series following the intervention. Global error rate decreased from 4.95 to 2.14% (-56.8%, P < 0.001). The safety of the medication process in our ICU was improved by simple and inexpensive interventions. In addition to the optimization of the prescription writing process, the documentation of intravenous preparation, and the scheduling of administration, the elimination of the transcription in combination with the training of users contributed to reducing errors and carried an interesting potential to increase safety. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.

[Causes, consequences and treatment of hypophosphatemia: A systematic review].

PubMed

Padelli, Maël; Leven, Cyril; Sakka, Mehdi; Plée-Gautier, Emmanuelle; Carré, Jean-Luc

2017-11-01

Although hypophosphatemia is usually very seldom, it can reach two to 3% of hospitalized patients and until 28% of intensive care unit patients. Due to the lack of knowledge, clinical practice regarding seeking or treatment of hypophosphatemia is very heterogenous. However its clinical consequences might be heavy. A better knowledge of its causes, physiopathological effects and treatment should lead to a documented and homogenous care of these patients in clinics. The aim of our study was a systematic review of littérature, seeking for publications about causes, consequences and treatment of hypophosphatemia. A research has been conducted on the Medline database by using the following keywords "phosphorus supplementation", "hypophosphatemia" and ("physiopathology" or "complications"). Three mains mechanisms might be responsible for hypophosphatemia: a decrease in digestive absorption, a rise in kidney excretion and a transfer of phosphorus to the intracellular compartment. Denutrition, acid base balance troubles, parenteral nutrition or several drugs are capable of provoking or favouring hypophosphatemia. All these situations are frequently encountered in intensive care unit. Consequences of hypophosphatemia might be serious. Best studied and documented are cardiac and respiratory muscle contractility decrease, sometimes leading to acute cardiac and respiratory failure, cardiac rhythm troubles and cardiac arrest. Hypophosphatemia is frequent during sepsis. It could be responsible for leucocyte dysfunction that might favour or increase sepsis. The treatment of hypophosphatemia is usually simple through a supplementation that quickly restores a regular concentration, with few adverse effects when regularly used. During at-risk situations, the systematic search for hypophosphatemia and its treatment may limit the occurrence of serious consequences. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

A Prevalence and Management Study of Acute Pain in Children Attending Emergency Departments by Ambulance.

PubMed

Murphy, Adrian; McCoy, Siobhan; O'Reilly, Kay; Fogarty, Eoin; Dietz, Jason; Crispino, Gloria; Wakai, Abel; O'Sullivan, Ronan

2016-01-01

Pain is the most common symptom in the emergency setting and remains one of the most challenging problems for emergency care providers, particularly in the pediatric population. The primary objective of this study was to determine the prevalence of acute pain in children attending emergency departments (EDs) in Ireland by ambulance. In addition, this study sought to describe the prehospital and initial ED management of pain in this population, with specific reference to etiology of pain, frequency of pain assessment, pain severity, and pharmacological analgesic interventions. A prospective cross-sectional study was undertaken over a 12-month period of all pediatric patients transported by emergency ambulance to four tertiary referral hospitals in Ireland. All children (<16 years) who had pain as a symptom (regardless of cause) at any stage during the prehospital phase of care were included in this study. Over the study period, 6,371 children attended the four EDs by emergency ambulance, of which 2,635 (41.4%, 95% confidence interval 40.2-42.3%) had pain as a documented symptom on the ambulance patient care report (PCR) form. Overall 32% (n = 856) of children who complained of pain were subject to a formal pain assessment during the prehospital phase of care. Younger age, short transfer time to the ED, and emergency calls between midnight and 6 am were independently associated with decreased likelihood of having a documented assessment of pain intensity during the prehospital phase of care. Of the 2,635 children who had documented pain on the ambulance PCR, 26% (n = 689) received some form of analgesic agent prior to ED arrival. Upon ED arrival 54% (n = 1,422) of children had a documented pain assessment and some form of analgesic agent was administered to 50% (n = 1,324). Approximately 41% of children who attend EDs in Ireland by ambulance have pain documented as their primary symptom. This study suggests that the management of acute pain in children transferred by ambulance to the ED in Ireland is currently poor, with documentary evidence of only 26% receiving prehospital analgesic agents.

A health partnership to reduce neonatal mortality in four hospitals in Rwanda.

PubMed

Ntigurirwa, Placide; Mellor, Kathy; Langer, Daniel; Evans, Mari; Robertson, Emily; Tuyisenge, Lisine; Groves, Alan; Lissauer, Tom

2017-06-01

A health partnership to improve hospital based neonatal care in Rwanda to reduce neonatal mortality was requested by the Rwandan Ministry of Health. Although many health system improvements have been made, there is a severe shortage of health professionals with neonatal training. Following a needs assessment, a health partnership grant for 2 years was obtained. A team of volunteer neonatologists and paediatricians, neonatal nurses, lactation consultants and technicians with experience in Rwanda or low-income countries was assembled. A neonatal training program was provided in four hospitals (the 2 University hospitals and 2 district hospitals), which focused on nutrition, provision of basic respiratory support with nasal CPAP (Continuous Positive Airway Pressure), enhanced record keeping, thermoregulation, vital signs monitoring and infection control. To identify if care delivery improved, audits of nutritional support, CPAP use and its complications, and documentation in newly developed neonatal medical records were conducted. Mortality data of neonatal admissions was obtained. Intensive neonatal training was provided on 27 short-term visits by 10 specialist health professionals. In addition, a paediatric doctor spent 3 months and two spent 6 months each providing training. A total of 472 training days was conducted in the neonatal units. For nutritional support, significant improvements were demonstrated in reduction in time to initiation of enteral feeds and to achieve full milk feeds, in reduction in maximum postnatal weight loss, but not in days for regaining birth weight. Respiratory support with bubble CPAP was applied to 365 infants in the first 18 months. There were no significant technical problems, but tissue damage, usually transient, to the nose and face was recorded in 13%. New medical records improved documentation by doctors, but nursing staff were reluctant to use them. Mortality for University teaching hospital admissions was reduced from 23.6% in the 18 months before the project to 21.7%. For the two district hospitals, mortality reduced from 10% to 8.1%. A major barrier to training and improved care was low number of nurses working on neonatal units and staff turnover. This health partnership delivered an intensive program of capacity building by volunteer specialists. Improved care and documentation were demonstrated. CPAP was successfully introduced. Mortality was reduced. This format can be adapted for further training and improvement programs to improve the quality of facility-based care.

Study in Parkinson Disease of Exercise (SPARX): Translating high-intensity exercise from animals to humans

PubMed Central

Moore, Charity G.; Schenkman, Margaret; Kohrt, Wendy M.; Delitto, Anthony; Hall, Deborah A.; Corcos, Daniel

2013-01-01

A burgeoning literature suggests that exercise has a therapeutic benefit in persons with Parkinson disease (PD) and in animal models of PD, especially when animals exercise at high intensity. If exercise is to be prescribed as “first-line” or “add-on” therapy in patients with PD, we must demonstrate its efficacy and dose-response effects through testing phases similar to those used in the testing of pharmacologic agents. The SPARX Trial is a multicenter, randomized, controlled, single-blinded, Phase II study that we designed to test the feasibility of using high-intensity exercise to modify symptoms of PD and to simultaneously test the nonfutility of achieving a prespecified change in patients’ motor scores on the Unified Parkinson Disease Rating Scale (UPDRS). The trial began in May 2102 and is in the process of screening, enrolling, and randomly assigning 126 patients with early-stage PD to 1 of 3 groups: usual care (wait-listed controls), moderate-intensity exercise (4 days/week at 60%–65% maximal heart rate [HRmax]), or high-intensity exercise (4 days/week at 80%–85% HRmax). At 6-month follow-up, the trial is randomly reassigning usual care participants to a moderate-intensity or high-intensity exercise group for the remaining 6 months. The goals of the Phase II trial are to determine if participants can exercise at moderate and high intensities; to determine if either exercise yields benefits consistent with meaningful clinical change (nonfutility); and to document safety and attrition. The advantage of using a non-futility approach allows us to efficiently determine if moderate- or high-intensity exercise warrants further large-scale investigation in PD. PMID:23770108

Health care professionals' pain narratives in hospitalized children's medical records. Part 1: pain descriptors.

PubMed

Rashotte, Judy; Coburn, Geraldine; Harrison, Denise; Stevens, Bonnie J; Yamada, Janet; Abbott, Laura K

2013-01-01

Although documentation of children's pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children. To describe health care professionals' use of written language related to the quality and quantity of pain experienced by hospitalized children. Free-text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used. Pain narratives were documented a total of 5390 times in 1518 of the 3822 children's medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (e.g., vocal, motor, facial and activities cues), affective and physiological cues, and children's descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers. The richness and complexity of vocabulary used by clinicians to document children's pain lend support to the concept that the word 'pain' is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children's pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals.

Lack of evidence and standardization in care pathway documents for patients with ST-elevated myocardial infarction.

PubMed

Aeyels, Daan; Van Vugt, Stijn; Sinnaeve, Peter R; Panella, Massimiliano; Van Zelm, Ruben; Sermeus, Walter; Vanhaecht, Kris

2016-04-01

Clinical practice variation and the subsequent burden on health care quality has been documented for patients with ST-elevated myocardial infarction (STEMI). Reduction of clinical practice variation is possible by increasing guideline adherence. Care pathway documents can increase guideline adherence by implementing evidence-based key interventions and quality indicators in daily practice. This study aims to examine guideline adherence of care pathway documents for patients with STEMI. Lay-out, size and timeframe of submitted care pathways documents were analysed. Two independent reviewers used a checklist to systematically assess the guideline adherence of care pathway documents. The checklist comprised a set of key interventions and quality indicators extracted from evidence and international guidelines. The checklist distinguished the evidence level for each item and was validated by expert consensus. Results were verified by inviting participating hospitals to provide feedback. Fifteen out of 25 invited hospitals submitted care pathway documents for STEMI. The care pathway documents differed in timeframe, lay-out and size. Analysis of the care pathway documents showed important variation in formalizing adherence to evidence: between hospitals, inclusion of 24 key interventions in care pathway documents varied from 13 to 97%. Inclusion of 11 essential quality indicators varied from 0 to 40%. Care pathway documents for patients with STEMI differ considerably in lay-out, timeframe and size. This study showed variation in, and suboptimal inclusion of, evidence-based key interventions and quality indicators in care pathway documents. The use of these care pathway documents might result in suboptimal quality of care for STEMI patients. © The European Society of Cardiology 2015.

[Intensive care medicine-survival and prospect of life].

PubMed

Valentin, A

2017-10-01

Intensive care medicine has achieved a significant increase in survival rates from critical illness. In addition to short-term outcomes like intensive care unit or hospital mortality, long-term prognosis and prospect of life of intensive care patients have recently become increasingly important. Pure survival is no longer a sole goal of intensive care medicine. The prediction of an intensive care patient's individual course should include the period after intensive care. A relevant proportion of all intensive care patients is affected by physical, psychological, cognitive, and social limitations after discharge from the intensive care unit. The prognosis of the status of the patient after discharge from the intensive care unit is an important part of the decision-making process with respect to the implementation or discontinuation of intensive care measures. The heavy burden of intensive care treatment should not solely be argued by pure survival but an anticipated sound prospect of life.

Using a personal digital assistant to document clinical pharmacy services in an intensive care unit.

PubMed

Lau, A; Balen, R M; Lam, R; Malyuk, D L

2001-07-01

Management Case Studies describe approaches to real-life management problems in health systems. Each installment is a brief description of a problem and how it was dealt with. The cases are intended to help readers deal with similar experiences in their own work sites. Problem solving, not hypothesis testing, is emphasized. Successful resolution of the management issue is not a criterion for publication--important lessons can be learned from failures, too.

End-of-life choices for African-American and white infants in a neonatal intensive-care unit: a pilot study.

PubMed Central

Moseley, Kathryn L.; Church, Annamaria; Hempel, Bridget; Yuan, Harry; Goold, Susan Door; Freed, Gary L.

2004-01-01

BACKGROUND: African-American adults are more likely than white adults to desire the continuation of life-sustaining medical treatment (LSMT) at the end of life. No studies have examined racial differences in parental end-of-life decisions for neonates. OBJECTIVE: To collect preliminary data to determine whether differences exist in the choices made by parents of African-American and white infants when a physician has recommended withholding or withdrawing LSMT from their infant to develop hypotheses for future work. DESIGN/METHODS: A retrospective chart review of African-American and white infants who died in an urban neonatal intensive care unit (NICU) over a two-year period. Charts were abstracted for demographics, cause of death, and documentation of meetings where the physician recommended withholding or withdrawing LSMT. RESULTS: Thirty-eight infant charts met study criteria (58% African-American, 42% white). Documentation of physician recommendations to limit LSMT was present in 61% of charts. Approached families of white infants agreed to limit LSMT 80% of the time compared to 62% of the families of African-American infants. CONCLUSIONS: In this pilot study, parents of African-American and white infants appeared to make different end-of-life choices for their children. A larger study is needed to confirm these findings and further explore contributing factors such as mistrust, religiosity, and perceived discrimination. PMID:15253324

Evidence for overuse of medical services around the world.

PubMed

Brownlee, Shannon; Chalkidou, Kalipso; Doust, Jenny; Elshaug, Adam G; Glasziou, Paul; Heath, Iona; Nagpal, Somil; Saini, Vikas; Srivastava, Divya; Chalmers, Kelsey; Korenstein, Deborah

2017-07-08

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide. Copyright © 2017 Elsevier Ltd. All rights reserved.

Documenting the NICU design dilemma: parent and staff perceptions of open ward versus single family room units

PubMed Central

Domanico, R; Davis, D K; Coleman, F; Davis, B O

2010-01-01

Objective: With neonatal intensive care units (NICUs) evolving from multipatient wards toward family-friendly, single-family room units, the study objective was to compare satisfaction levels of families and health-care staff across these differing NICU facility designs. Study Design: This prospective study documented, by means of institutional review board-approved questionnaire survey protocols, the perceptions of parents and staff from two contrasting NICU environments. Result: Findings showed that demographic subgroups of parents and staff perceived the advantages and disadvantages of the two facility designs differently. Staff perceptions varied with previous experience, acclimation time and employment position, whereas parental perceptions revealed a naiveté bias through surveys of transitional parents with experience in both NICU facilities. Conclusion: Use of transitional parent surveys showed a subject naiveté bias inherent in perceptions of inexperienced parents. Grouping all survey participants demographically provided more informative interpretations of data, and revealed staff perceptions to vary with position, previous training and hospital experience. PMID:20072132

Hospital policy on medical futility - does it help in conflict resolution and ensuring good end-of-life care?

PubMed

Joseph, Roy

2011-01-01

This paper aimed to ascertain if hospital policy on medical futility helps in conflict resolution, and in ensuring good end-of-life care. Literature on the subject published in the last 5 years was identified through Pubmed, and those with empirical data pertaining to the outcomes of interest were examined. A systematic analysis was not possible as papers varied greatly in aims, designs, outcomes and their measures. Instead, the outcomes of representative papers were described and discussed. There is a widespread use of policies and guidelines based on the concept of medical futility. Conflicts are rare and appear to arise primarily from the manner in which policies are implemented. End-of-life care appears to be improving as evidenced by a significant number of deaths occurring following: (i) discussions involving patient, family, healthcare team members; (ii) cessation of intensive care and (iii) cessation of institution of palliative care. Deaths are increasingly taking place in the presence of family and outside the intensive care wards. Finally, post mortem audit of processes and practices indicate (i) compliance but in a limited manner with policies and recommended guidelines, (ii) family satisfaction and (iii) identify areas where improvement in end-of-life (EOL) care can be effected. Key areas are in improving education of, communication with, and documentation by all stakeholders. Hospital policies on medical futility have helped to resolve conflicts and improve end-of-life care. Prospective, multicentre and controlled trials will be useful in determining the value of specific interventions, obtaining generalisable data and facilitating implementation of better end-of-life care models.

[The National Database of the Regional Collaborative Rheumatic Centers as a tool for clinical epidemiology and quality assessment in rheumatology].

PubMed

Zink, Angela; Huscher, Dörte; Listing, Joachim

2003-01-01

The national database of the German Collaborative Arthritis Centres is a well-established tool for the observation and assessment of health care delivery to patients with rheumatic diseases in Germany. The discussion of variations in treatment practices contributes to the internal quality assessment in the participating arthritis centres. This documentation has shown deficits in primary health care including late referral to a rheumatologist, undertreatment with disease-modifying drugs and complementary therapies. In rheumatology, there is a trend towards early, intensive medical treatment including combination therapy. The frequency and length of inpatient hospital and rehabilitation treatments is decreasing, while active physiotherapy in outpatient care has been increased. Specific deficits have been identified concerning the provision of occupational therapy services and patient education.

The future of telemedicine for the management of heart failure patients: a Consensus Document of the Italian Association of Hospital Cardiologists (A.N.M.C.O), the Italian Society of Cardiology (S.I.C.) and the Italian Society for Telemedicine and eHealth (Digital S.I.T.)

PubMed Central

Casolo, Giancarlo; Gulizia, Michele Massimo; Aspromonte, Nadia; Scalvini, Simonetta; Mortara, Andrea; Alunni, Gianfranco; Ricci, Renato Pietro; Mantovan, Roberto; Russo, Giancarmine; Gensini, Gian Franco; Romeo, Francesco

2017-01-01

Abstract Telemedicine applied to heart failure patients is a tool for recording and providing remote transmission, storage and interpretation of cardiovascular parameters and/or useful diagnostic images to allow for intensive home monitoring of patients with advanced heart failure, or during the vulnerable post-acute phase, to improve patient’s prognosis and quality of life. Recently, several meta-analyses have shown that telemedicine-supported care pathways are not only effective but also economically advantageous. Benefits seem to be substantial, with a 30–35% reduction in mortality and 15–20% decrease in hospitalizations. Patients implanted with cardiac devices can also benefit from an integrated remote clinical management since all modern devices can transmit technical and diagnostic data. However, telemedicine may provide benefits to heart failure patients only as part of a shared and integrated multi-disciplinary and multi-professional ‘chronic care model’. Moreover, the future development of remote telemonitoring programs in Italy will require the primary use of products certified as medical devices, validated organizational solutions as well as legislative and administrative adoption of new care methods and the widespread growth of clinical care competence to remotely manage the complexity of chronicity. Through this consensus document, Italian Cardiology reaffirms its willingness to contribute promoting a new phase of qualitative assessment, standardization of processes and testing of telemedicine-based care models in heart failure. By recognizing the relevance of telemedicine for the care of non-hospitalized patients with heart failure, its strategic importance for the design of innovative models of care, and the many challenges and opportunities it raises, ANMCO and SIC through this document report a consensus on the main directions for its widespread and sustainable clinical implementation PMID:28751839

The future of telemedicine for the management of heart failure patients: a Consensus Document of the Italian Association of Hospital Cardiologists (A.N.M.C.O), the Italian Society of Cardiology (S.I.C.) and the Italian Society for Telemedicine and eHealth (Digital S.I.T.).

PubMed

Di Lenarda, Andrea; Casolo, Giancarlo; Gulizia, Michele Massimo; Aspromonte, Nadia; Scalvini, Simonetta; Mortara, Andrea; Alunni, Gianfranco; Ricci, Renato Pietro; Mantovan, Roberto; Russo, Giancarmine; Gensini, Gian Franco; Romeo, Francesco

2017-05-01

Telemedicine applied to heart failure patients is a tool for recording and providing remote transmission, storage and interpretation of cardiovascular parameters and/or useful diagnostic images to allow for intensive home monitoring of patients with advanced heart failure, or during the vulnerable post-acute phase, to improve patient's prognosis and quality of life. Recently, several meta-analyses have shown that telemedicine-supported care pathways are not only effective but also economically advantageous. Benefits seem to be substantial, with a 30-35% reduction in mortality and 15-20% decrease in hospitalizations. Patients implanted with cardiac devices can also benefit from an integrated remote clinical management since all modern devices can transmit technical and diagnostic data. However, telemedicine may provide benefits to heart failure patients only as part of a shared and integrated multi-disciplinary and multi-professional 'chronic care model'. Moreover, the future development of remote telemonitoring programs in Italy will require the primary use of products certified as medical devices, validated organizational solutions as well as legislative and administrative adoption of new care methods and the widespread growth of clinical care competence to remotely manage the complexity of chronicity. Through this consensus document, Italian Cardiology reaffirms its willingness to contribute promoting a new phase of qualitative assessment, standardization of processes and testing of telemedicine-based care models in heart failure. By recognizing the relevance of telemedicine for the care of non-hospitalized patients with heart failure, its strategic importance for the design of innovative models of care, and the many challenges and opportunities it raises, ANMCO and SIC through this document report a consensus on the main directions for its widespread and sustainable clinical implementation.

"Open your heart first of all": perspectives of holistic providers in Costa Rica about communication in the provision of health care.

PubMed

Geist-Martin, Patricia; Bell, Keely K

2009-10-01

Research documents how the care the holistic providers offer represents the quality communication that patients often do not receive from their biomedical providers. However, research investigating the perspectives of holistic providers concerning the role they see themselves playing in the provision of health is limited. This research explores the perceptions of holistic providers in Costa Rica about their communication with their patients. The results reveal two practices of communication-authenticating and integrating as central to providers' communication with patients in the provision of holistic health care. Providers describe their communication as an exploration of an anatomy of pain/suffering, including investigating the location, timing, length, intensity, and overall rhythm of the patient's condition and sense making that leads them to seek the care of a holistic provider. Most holistic providers see their role as being careful or full of care and suggest that they have an obligation to open their heart first of all.

The last three days of life: a comparison of pain management in the young old and the oldest old hospitalised patients using the Resident Assessment Instrument for Palliative Care.

PubMed

Steindal, Simen Alexander; Bredal, Inger Schou; Ranhoff, Anette Hylen; Sørbye, Liv Wergeland; Lerdal, Anners

2015-12-01

Pain is a common symptom in older patients at the end of life. Little research has evaluated pain management among the oldest hospitalised dying patients. To compare the pain characteristics documented by healthcare workers for the young old and the oldest old hospitalised patients and the types of analgesics administered in the last three days of life. A retrospective cross-sectional comparative study. The study included 190 patients from a Norwegian general hospital: 101 young old patients (aged 65-84 years) and 89 oldest old patients (aged 85-100 years). Data were extracted from electronic patient records (EPRs) using the Resident Assessment Instrument for Palliative Care. No significant differences were found between the young old and the oldest old patients with regard to pain characteristics. Pain intensity was poorly recorded in the EPRs. Most of the patients received adequate pain control. Morphine was the most frequently administered analgesic for dying patients. Compared to the oldest old patients, a greater proportion of the young old patients received paracetamol combined with codeine (OR = 3.25, 95% CI 1.02-10.40). There appeared to be no differences in healthcare workers' documentation of pain characteristics in young old and oldest old patients, but young old patients were more likely to receive paracetamol in combination with codeine. A limitation of the study is the retrospective design and that data were collected from a single hospital. Therefore, caution should be taken for interpretation of the results. The use of systematic patient-reported assessments in combination with feasible validated tools could contribute to more comprehensive documentation of pain intensity and improved pain control. © 2014 John Wiley & Sons Ltd.

Helping cancer patients across the care continuum: the navigation program at the Queen's Medical Center.

PubMed

Allison, Amanda L; Ishihara-Wong, Debra D M; Domingo, Jermy B; Nishioka, Jocelyn; Wilburn, Andrea; Tsark, JoAnn U; Braun, Kathryn L

2013-04-01

Research suggests that cancer patient navigation improves care, but few reports describe the variety of patients managed by a hospital-based navigation program. Differences in navigated patients by the intensity (low, medium, or high) of navigation services they received were examined. The 835 clients seen by the navigators in a hospital-based cancer center were first stratified by quarter and by four ethnic groups. Randomized selection from each group assured there would be equal representation for analysis of Hawaiians, Filipinos, Japanese, and Whites and even numbers over all time intervals. Five professionals extracted data from these case records on demographics, type/stage of cancer, diagnosis and treatment dates, barriers, and navigator actions. Clients had breast (30.0%), lung (15.8%), esophageal (6.7%), colon (5.8%), ovarian (4.2%), prostate (3.3%), and other cancers (34.2%). The median number of actions taken on behalf of a client was 4 (range 1-83), and the median number of days a case was open was 14 (range 1-216). High intensity cases (those receiving more assistance over longer periods of time) were more likely than low-intensity cases to need help with education and reassurance, transportation, care coordination, and covering costs. Although there were no demographic differences across intensity groups, Neighbor Island patients from Hawai'i, Maui, Moloka'i, Lana'i and Kaua'i were more likely to need help with arranging travel, care coordination, and costs associated with getting treatment (all at P=.05), and patients on public insurance were more likely to have stage 4 cancer (P=.001) and to need help with costs (P=.006). Findings suggest that this hospital-based navigation program is filling a real need of patients across the cancer care continuum. A triage protocol and an integrated data capture system could help improve the targeting and documentation of cancer patient navigation services.

Male-female patient differences in association between end-of-life discussions and receipt of intensive care near death

PubMed Central

Sharma, Rashmi K.; Prigerson, Holly G.; Penedo, Frank J.; Maciejewski, Paul K.

2015-01-01

Background Patient gender plays a significant role in patient-physician communication, patient illness understanding and aggressiveness of end of life (EoL) care. However, little is known about the extent to which gender differences in the effects of EoL discussions on EoL care contribute to gender differences in EoL care. The present study aims to determine if gender differences exist in receipt of intensive care unit (ICU) care near death and in the association between EoL discussions and receipt of ICU EoL care. Methods Multi-site, prospective, cohort study of patients (N=353) with metastatic cancers, identified as terminally ill at study enrollment and interviewed a median of 4.1 months before their deaths. Postmortem chart reviews and caregiver interviews documented ICU stays in the last week of life. Results Patients who received ICU care at the EoL were more likely to be male than those who did not (73% male vs. 52% male, p=0.02). Adjusting for potential confounds, male patients reporting an EoL discussion were less likely to have an ICU stay in the last week of life than male patients with no EoL discussion (AOR=0.26, 95% CI 0.07–0.91; p=0.04). There was no association between EoL discussions and ICU stays near death among female patients. Conclusions Men with advanced cancers are more likely than women to receive aggressive, non-beneficial, ICU care near death. Gender differences in effects of EoL discussions on EoL care likely contribute to, and may even explain, gender differences in receipt of ICU care in the last week of life. PMID:25975179

Caffeine use in the neonatal intensive care unit.

PubMed

Abu-Shaweesh, Jalal M; Martin, Richard J

2017-10-01

Caffeine is the most frequently used medication in the neonatal intensive care unit. It is used for the prevention and treatment of apnea, although this has been associated with lower incidence of bronchopulmonary dysplasia (BPD) and patent ductus arteriosus as well as intact survival at 18-21 months of life. Although neurodevelopmental advantage was no longer statistically significant at age 5 years, caffeine was associated with sustained improvement in co-ordination and less gross motor impairment than placebo. The mechanism of action of caffeine on prevention of apnea and activation of breathing seems to be through central inhibition of adenosine receptors. However, its impact on BPD and neurodevelopmental outcomes might be induced through its effects as anti-inflammatory mediator, protection of white matter, and induction of surfactant protein B. Whereas long-term studies have documented the safety of caffeine as used in current practice, further studies are clearly needed to identify optimum dosing, and time of starting and discontinuing caffeine. Copyright © 2017 Elsevier Ltd. All rights reserved.

Dialectical Behavior Therapy Training and Desired Resources for Implementation: Results From a National Program Evaluation in the Veterans Health Administration.

PubMed

Landes, Sara J; Matthieu, Monica M; Smith, Brandy N; Trent, Lindsay R; Rodriguez, Allison L; Kemp, Janet; Thompson, Caitlin

2016-08-01

Little is known about nonresearch training experiences of providers who implement evidence-based psychotherapies for suicidal behaviors among veterans. This national program evaluation identified the history of training, training needs, and desired resources of clinicians who work with at-risk veterans in a national health care system. This sequential mixed methods national program evaluation used a post-only survey design to obtain needs assessment data from clinical sites (N = 59) within Veterans Health Administration (VHA) facilities that implemented dialectical behavior therapy (DBT). Data were also collected on resources preferred to support ongoing use of DBT. While only 33% of clinical sites within VHA facilities reported that staff attended a formal DBT intensive training workshop, nearly 97% of participating sites reported having staff who completed self-study using DBT manuals. Mobile apps for therapists and clients and templates for documentation in the electronic health records to support measurement-based care were desired clinical resources. Results indicate that less-intensive training models can aid staff in implementing DBT in real-world health care settings. While more training is requested, a number of VHA facilities have successfully implemented DBT into the continuum of care for veterans at risk for suicide. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

Surviving "Payment by Results": a simple method of improving clinical coding in burn specialised services in the United Kingdom.

PubMed

Wallis, Katy L; Malic, Claudia C; Littlewood, Sonia L; Judkins, Keith; Phipps, Alan R

2009-03-01

Coding inpatient episodes plays an important role in determining the financial remuneration of a clinical service. Insufficient or incomplete data may have very significant consequences on its viability. We created a document that improves the coding process in our Burns Centre. At Yorkshire Regional Burns Centre an inpatient summary sheet was designed to prospectively record and present essential information on a daily basis, for use in the coding process. The level of care was also recorded. A 3-month audit was conducted to assess the efficacy of the new forms. Forty-nine patients were admitted to the Burns Centre with a mean age of 27.6 years and TBSA ranging from 0.5% to 65%. The total stay in the Burns Centre was 758 days, of which 22% were at level B3-B5 and 39% at level B2. The use of the new discharge document identified potential income of about 500,000 GB pound sterling at our local daily tariffs for high dependency and intensive care. The new form is able to ensure a high quality of coding with a possible direct impact on the financial resources accrued for burn care.

Strategies to address management challenges in larger intensive care units.

PubMed

Matlakala, M C; Bezuidenhout, M C; Botha, A D H

2015-10-01

To illustrate the need for and suggest strategies that will enhance sustainable management of a large intensive care unit (ICU). The challenges faced by intensive care nursing in South Africa are well documented. However, there appear to be no strategies available to assist nurses to manage large ICUs or for ICU managers to deal with problems as they arise. Data sources to illustrate the need for strategies were challenges described by ICU managers in the management of large ICUs. A purposive sample of managers was included in individual interviews during compilation of evidence regarding the challenges experienced in the management of large ICUs. The challenges were presented at the Critical Care Society of Southern Africa Congress held on 28 August to 2 September 2012 in Sun City North-West province, South Africa. Five strategies are suggested for the challenges identified: divide the units into sections; develop a highly skilled and effective nursing workforce to ensure delivery of quality nursing care; create a culture to retain an effective ICU nursing team; manage assets; and determine the needs of ICU nurses. ICUs need measures to drive the desired strategies into actions to continuously improve the management of the unit. Future research should be aimed at investigating the effectiveness of the strategies identified. This research highlights issues relating to large ICUs and the strategies will assist ICU managers to deal with problems related to large unit sizes, shortage of trained ICU nurses, use of agency nurses, shortage of equipment and supplies and stressors in the ICU. The article will make a contribution to the body of nursing literature on management of ICUs. © 2014 John Wiley & Sons Ltd.

Family influence and psychiatric care: Physical treatments in Devon mental hospitals, c. 1920 to the 1970s☆

PubMed Central

Baur, Nicole

2013-01-01

‘What is it that appears to make the mentally ill so vulnerable to therapeutic experimentation?’1 One commentator wrote in the 1990s, regarding mental hospitals as repressive, coercive and custodial institutions where medical staff subjected patients to orgies of experimentation. A careful study of surviving documents of the Devon County Lunatic Asylum (DCLA), however, paints a different picture. Rather than medical staff, patients’ relatives and the wider community exercised a considerable influence over a patient's hospital admission and discharge, rendering the therapeutic regime in the middle of the 20th century the result of intense negotiations between the hospital and third parties. PMID:23876990

[Sponsorship, conflict of interest and corruption: promoting science in discussion of medical ethics].

PubMed

Frewer, A

2002-01-01

Even in health care systems corruption is an increasing problem. Since the German Anti-Corruption-Law (1997) the areas of financial support, sponsoring and corruption in medicine are analyzed much more intensively. This article sketches the crucial points of the debate on medical funding and shows the consequences of the new jurisdiction. Most important is the balance between a transparent documentation and a too-far-reaching bureaucracy, which hinders medical research. Finally, this article presents core principles as helpful rules in practice.

The "TRAUMA LIFE" initiative: The impact of a multidisciplinary checklist process on outcomes and communication in a Trauma Intensive Care Unit.

PubMed

Joseph, Kimberly; Gupta, Sameer; Yon, James; Partida, Renee; Cartagena, Lee; Kubasiak, John; Buie, Vanessa; Miller, Jared; Wiley, Dorion; Nagy, Kimberly; Starr, Frederic; Dennis, Andrew; Kaminsky, Matthew; Bokhari, Faran

2018-03-09

Checklists have been advocated to improve quality outcomes/communication in the critical care setting, but results have been mixed. A new checklist process, "TRAUMA LIFE", was implemented in our Trauma Intensive Care Unit (TICU) to replace prior checklists. The purpose of this study was to evaluate the impact of the "TRAUMA LIFE" process implementation on quality metrics and on patient/family communication in the TICU. "TRAUMA LIFE" was considered maturely implemented by 2016. Multiple quality metrics, including restraint order compliance, were compared between 2013 and 2016 (pre- and post-implementation). Compliance with the "Family Message" (FM), a part of the "TRAUMA LIFE" communication process, was analyzed in 2016. Improvement was seen in CAUTI, VAE, and IUCU; CLABSI rates increased. Restraint order compliance increased significantly. FM delivery compliance was inconsistent; improvement was noted in concordance between update content and FM documented in Electronic Medical Record. Implementation of "TRAUMA LIFE" was well integrated into the rounding process and was associated with some improvement in quality metrics and communication. Additional evaluation is required to assess sustainability. Copyright © 2018 Elsevier Inc. All rights reserved.

Documentation of pain care processes does not accurately reflect pain management delivered in primary care.

PubMed

Krebs, Erin E; Bair, Matthew J; Carey, Timothy S; Weinberger, Morris

2010-03-01

Researchers and quality improvement advocates sometimes use review of chart-documented pain care processes to assess the quality of pain management. Studies have found that primary care providers frequently fail to document pain assessment and management. To assess documentation of pain care processes in an academic primary care clinic and evaluate the validity of this documentation as a measure of pain care delivered. Prospective observational study. 237 adult patients at a university-affiliated internal medicine clinic who reported any pain in the last week. Immediately after a visit, we asked patients to report the pain treatment they received. Patients completed the Brief Pain Inventory (BPI) to assess pain severity at baseline and 1 month later. We extracted documentation of pain care processes from the medical record and used kappa statistics to assess agreement between documentation and patient report of pain treatment. Using multivariable linear regression, we modeled whether documented or patient-reported pain care predicted change in pain at 1 month. Participants' mean age was 53.7 years, 66% were female, and 74% had chronic pain. Physicians documented pain assessment for 83% of visits. Patients reported receiving pain treatment more often (67%) than was documented by physicians (54%). Agreement between documentation and patient report was moderate for receiving a new pain medication (k = 0.50) and slight for receiving pain management advice (k = 0.13). In multivariable models, documentation of new pain treatment was not associated with change in pain (p = 0.134). In contrast, patient-reported receipt of new pain treatment predicted pain improvement (p = 0.005). Chart documentation underestimated pain care delivered, compared with patient report. Documented pain care processes had no relationship with pain outcomes at 1 month, but patient report of receiving care predicted clinically significant improvement. Chart review measures may not accurately reflect the pain management patients receive in primary care.

Protocolised approach to end-of-life care in the ICU--the ICU PALCare Pilot Project.

PubMed

Rajamani, A; Barrett, E; Weisbrodt, L; Bourne, J; Palejs, P; Gresham, R; Huang, S

2015-05-01

International literature on end-of-life care in intensive care units (ICUs) supports the use of 'protocol bundles', which is not common practice in our 18-bed adult general ICU in Sydney, New South Wales. We conducted a prospective observational study to identify problems related to end-of-life care practices and to determine whether there was a need to develop protocol bundles. Any ICU patient who had 'withdrawal' of life-sustaining treatment to facilitate a comfortable death was eligible. Exclusion criteria included organ donors, unsuitable family dynamics and lack of availability of research staff to obtain family consent. Process-of-care measures were collected using a standardised form. Satisfaction ratings were obtained using de-identified questionnaire surveys given to the healthcare staff shortly after the withdrawal of therapy and to the families 30 days later. Twenty-three patients were enrolled between June 2011 and July 2012. Survey questionnaires were given to 25 family members and 30 healthcare staff, with a high completion rate (24 family members [96%] and 28 staff [93.3%]). Problems identified included poor documentation of family meetings (39%) and symptom management. Emotional/spiritual support was not offered to families (39.1%) or ICU staff (0%). The overall level of end-of-life care was good. The overwhelming majority of families and healthcare staff were highly satisfied with the care provided. Problems identified related to communication documentation and lack of spiritual/emotional support. To address these problems, targeted measures would be more useful than the adoption of protocol bundles. Alternate models of satisfaction surveys may be needed.

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

PubMed Central

Price, Susanna; Via, Gabriele; Sloth, Erik; Guarracino, Fabio; Breitkreutz, Raoul; Catena, Emanuele; Talmor, Daniel

2008-01-01

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways – either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level – obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs. PMID:18837986

Feasibility of hospital-initiated non-facilitator assisted advance care planning documentation for patients with palliative care needs.

PubMed

Kok, Maaike; van der Werff, Gertruud F M; Geerling, Jenske I; Ruivenkamp, Jaap; Groothoff, Wies; van der Velden, Annette W G; Thoma, Monique; Talsma, Jaap; Costongs, Louk G P; Gans, Reinold O B; de Graeff, Pauline; Reyners, Anna K L

2018-05-24

Advance Care Planning (ACP) and its documentation, accessible to healthcare professionals regardless of where patients are staying, can improve palliative care. ACP is usually performed by trained facilitators. However, ACP conversations would be more tailored to a patient's specific situation if held by a patient's clinical healthcare team. This study assesses the feasibility of ACP by a patient's clinical healthcare team, and analyses the documented information including current and future problems within the palliative care domains. This multicentre study was conducted at the three Groningen Palliative Care Network hospitals in the Netherlands. Patients discharged from hospital with a terminal care indication received an ACP document from clinical staff (non-palliative care trained staff at hospitals I and II; specialist palliative care nurses at hospital III) after they had held ACP conversations. An anonymised copy of this ACP document was analysed. Documentation rates of patient and contact details were investigated, and documentation of current and future problems were analysed both quantitatively and qualitatively. One hundred sixty ACP documents were received between April 2013 and December 2014, with numbers increasing for each consecutive 3-month time period. Advance directives were frequently documented (82%). Documentation rates of current problems in the social (24%), psychological (27%) and spiritual (16%) domains were low compared to physical problems (85%) at hospital I and II, but consistently high (> 85%) at hospital III. Of 545 documented anticipated problems, 92% were physical or care related in nature, 2% social, 5% psychological, and < 1% spiritual. Half of the anticipated non-physical problems originated from hospital III. Hospital-initiated ACP documentation by a patient's clinical healthcare team is feasible: the number of documents received per time period increased throughout the study period, and overall, documentation rates were high. Nonetheless, symptom documentation predominantly regards physical symptoms. With the involvement of specialist palliative care nurses, psychological and spiritual problems are addressed more frequently. Whether palliative care education for non-palliative care experts will improve identification and documentation of non-physical problems remains to be investigated.

Response to Early Intensive Behavioral Intervention for autism--an umbrella approach to issues critical to treatment individualization.

PubMed

Fava, Leonardo; Strauss, Kristin

2014-12-01

Integrating knowledge across the disciplines of genetics, neurological, and behavioral science targets, so far, early identification of children with autism and thus early access to intervention. Cross-discipline collaboration might be substantially improve treatment efficacy via individualized treatment based on the child and family needs, consistency across treatment providers and careful planning of skill curricula, setting and techniques. This paper documents the current state of five main issues critical to treatment individualization where cross-discipline collaboration is warranted: (1) developmental timing, (2) treatment intensity, (3) heterogeneity in treatment response, (4) program breath and flexibility, and (5) formats of treatment provision. Copyright © 2014 ISDN. Published by Elsevier Ltd. All rights reserved.

Pressure injury prevalence in intensive care versus non-intensive care patients: A state-wide comparison.

PubMed

Coyer, Fiona; Miles, Sandra; Gosley, Sandra; Fulbrook, Paul; Sketcher-Baker, Kirstine; Cook, Jane-Louise; Whitmore, Jacqueline

2017-09-01

Hospital-acquired pressure injury is associated with increased morbidity and mortality and considered to be largely preventable. Pressure injury prevalence is regarded as a marker of health care quality. To compare the state-wide prevalence, severity and location of pressure injuries of intensive care unit patients compared to patients in non-intensive care wards. The study employed a secondary data analysis design to extract and analyse de-identified pressure injury data from all Queensland Health hospitals with level I-III intensive care facilities that participated in Queensland Bedside Audits between 2012-2014. The sample included all adult ICU and non-ICU patients that provided consent for the Queensland Bedside Audits, excluding those in mental health units. Excluding Stage I, overall hospital-acquired pressure injury prevalence from 2012 to 2014 was 11% for intensive care patients and 3% for non-intensive care patients. Intensive care patients were 3.8 times more likely (RR 2.7-5.4, 95% CI) than non-intensive care patients to develop a pressure injury whilst in hospital. The sacrum/coccyx was the most common site of hospital-acquired pressure injury in all patients (intensive care patients 22%; non-intensive care patients 35%) however, mucosal pressure injury proportion was significantly higher in intensive care patients (22%) than in non-intensive care patients (2%). Stage II HAPI prevalence was the most common stage reported, 53% for intensive care patients compared to 63% for non-intensive care patients. There are significant differences in hospital-acquired pressure injury prevalence by stage and location between intensive care and non-intensive care patients reflecting the possible impact of critical illness on the development of skin injury. This has implications for resource funding for pressure injury prevention and the imposition of government initiated financial penalties for hospital-acquired pressure injury. For future comparisons to be effective between intensive care units, benchmarking partners should share similar characteristics and relevant targets. Copyright © 2016 Australian College of Critical Care Nurses Ltd. All rights reserved.

Model Development for EHR Interdisciplinary Information Exchange of ICU Common Goals

PubMed Central

Collins, Sarah A.; Bakken, Suzanne; Vawdrey, David K.; Coiera, Enrico; Currie, Leanne

2010-01-01

Purpose 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. Methods The theoretical frameworks of distributed cognition and the clinical communication space were integrated and a previously published categorization of verbal information exchange was used. 59.5 hours of interdisciplinary rounds in a Neurovascular ICU were observed and five interviews and one focus group with ICU nurses and physicians were conducted. Results 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. Conclusion 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. PMID:20974549

The Influence of Race/Ethnicity and Socioeconomic Status on End-of-Life Care in the ICU

PubMed Central

Muni, Sarah; Engelberg, Ruth A.; Treece, Patsy D.; Dotolo, Danae

2011-01-01

Background: There is conflicting evidence about the influence of race/ethnicity on the use of intensive care at the end of life, and little is known about the influence of socioeconomic status. Methods: We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services. Results: Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79%) were white and 659 (21%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care. Conclusions: We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues. Trial registry: ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov PMID:21292758

The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study.

PubMed

Wang, Ning; Yu, Ping; Hailey, David

2015-08-01

The nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated. To describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans. A nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study. There was a tendency to omit 'nursing problem' or 'nursing diagnosis' in the nursing process by changing these terms (used in the paper-based care plan) to 'observation' in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P<0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P<0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes. The overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses' attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Patient stress in intensive care: comparison between a coronary care unit and a general postoperative unit

PubMed Central

Dias, Douglas de Sá; Resende, Mariane Vanessa; Diniz, Gisele do Carmo Leite Machado

2015-01-01

Objective To evaluate and compare stressors identified by patients of a coronary intensive care unit with those perceived by patients of a general postoperative intensive care unit. Methods This cross-sectional and descriptive study was conducted in the coronary intensive care and general postoperative intensive care units of a private hospital. In total, 60 patients participated in the study, 30 in each intensive care unit. The stressor scale was used in the intensive care units to identify the stressors. The mean score of each item of the scale was calculated followed by the total stress score. The differences between groups were considered significant when p < 0.05. Results The mean ages of patients were 55.63 ± 13.58 years in the coronary intensive care unit and 53.60 ± 17.47 years in the general postoperative intensive care unit. For patients in the coronary intensive care unit, the main stressors were “being in pain”, “being unable to fulfill family roles” and “being bored”. For patients in the general postoperative intensive care unit, the main stressors were “being in pain”, “being unable to fulfill family roles” and “not being able to communicate”. The mean total stress scores were 104.20 ± 30.95 in the coronary intensive care unit and 116.66 ± 23.72 (p = 0.085) in the general postoperative intensive care unit. When each stressor was compared separately, significant differences were noted only between three items. “Having nurses constantly doing things around your bed” was more stressful to the patients in the general postoperative intensive care unit than to those in the coronary intensive care unit (p = 0.013). Conversely, “hearing unfamiliar sounds and noises” and “hearing people talk about you” were the most stressful items for the patients in the coronary intensive care unit (p = 0.046 and 0.005, respectively). Conclusion The perception of major stressors and the total stress score were similar between patients in the coronary intensive care and general postoperative intensive care units. PMID:25909309

Sustained Reduction in Bloodstream Infections in Infants at a Large Tertiary Care Neonatal Intensive Care Unit

PubMed Central

Neill, Sara; Haithcock, Sarah; Smith, P. Brian; Goldberg, Ronald; Bidegain, Margarita; Tanaka, David; Carriker, Charlene; Ericson, Jessica E.

2015-01-01

Purpose Reduction of bloodstream infections (BSI) has emerged as an important patient safety goal. Implementation of central line insertion bundles, standardized line care protocols, and health care provider education programs have reduced BSI in neonatal intensive care units (NICUs) around the country. The ability of large tertiary care centers to decrease nosocomial infections, including BSI, has been demonstrated. However, long-term BSI reductions in infants are not well documented. We sought to demonstrate that a low incidence of BSI can be maintained over time in a tertiary care NICU. Subjects 6,790 infants admitted to a large, tertiary care NICU between 2005 and 2013. Design Retrospective intervention study. Methods A staged, multifaceted infection prevention plan was implemented beginning in October 2007 under nursing leadership. The incidence of BSI was determined annually for 2005-2013. Results Baseline BSI incidence for infants admitted to the NICU was 5.15 and 6.08 episodes per 1,000 infant-days in 2005 and 2006, respectively. After protocol implementation, the incidence of BSI decreased to 2.14/1,000 infant-days and 2.44/1,000 infant-days in 2008 and 2009, respectively. Yearly incidence remained low over the next 4 years and decreased even further to 0.20-0.45 infections/1,000 infant days. This represents a 92% decrease in BSI over a period of >5 years. Conclusions Implementation of a nursing-led comprehensive infection control initiative can effectively produce and maintain a reduction in the incidence of BSI in infants at a large tertiary care NICU. What this study adds Long term reductions in neonatal BSI are possible with implementation of a multidisciplinary team approach and strong nursing leadership. PMID:25915573

The relationship between organizational culture and family satisfaction in critical care.

PubMed

Dodek, Peter M; Wong, Hubert; Heyland, Daren K; Cook, Deborah J; Rocker, Graeme M; Kutsogiannis, Demetrios J; Dale, Craig; Fowler, Robert; Robinson, Sandra; Ayas, Najib T

2012-05-01

Family satisfaction with critical care is influenced by a variety of factors. We investigated the relationship between measures of organizational and safety culture, and family satisfaction in critical care. We further explored differences in this relationship depending on intensive care unit survival status and length of intensive care unit stay of the patient. Cross-sectional surveys. Twenty-three tertiary and community intensive care units within three provinces in Canada. One thousand two-hundred eighty-five respondents from 2374 intensive care unit clinical staff, and 880 respondents from 1381 family members of intensive care unit patients. None. Intensive care unit staff completed the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture. Family members completed the Family Satisfaction in the Intensive Care Unit 24, a validated survey of family satisfaction. A priori, we analyzed adjusted relationships between each domain score from the culture surveys and either satisfaction with care or satisfaction with decision-making for each of four subgroups of family members according to patient descriptors: intensive care unit survivors who had length of intensive care unit stay <14 days or >14 days, and intensive care unit nonsurvivors who had length of stay <14 days or ≥14 days. We found strong positive relationships between most domains of organizational and safety culture, and satisfaction with care or decision-making for family members of intensive care unit nonsurvivors who spent at least 14 days in the intensive care unit. For the other three groups, there were only a few weak relationships between domains of organizational and safety culture and family satisfaction. Our findings suggest that the effect of organizational culture on care delivery is most easily detectable by family members of the most seriously ill patients who interact frequently with intensive care unit staff, who are intensive care unit nonsurvivors, and who spend a longer time in the intensive care unit. Positive relationships between measures of organizational and safety culture and family satisfaction suggest that by improving organizational culture, we may also improve family satisfaction.

Measuring Outcomes of an Intensive Care Unit Family Diary Program.

PubMed

Huynh, Truong-Giang; Covalesky, Miranda; Sinclair, Samantha; Gunter, Heather; Norton, Tamara; Chen, Alice; Yi, Cassia

2017-01-01

Patients discharged from intensive care units are at risk of short- and long-term physical, cognitive, and emotional symptoms known as post-intensive care syndrome. Family members of intensive care unit patients are at risk of similar symptoms known as post-intensive care syndrome-family. Both syndromes are common, and strategies to reduce risk factors should be employed. An intensive care unit diary project to help reduce these syndromes was implemented in 2 intensive care units using an evidence-based framework. The effects of these diaries were studied using the Family Satisfaction with Care in the Intensive Care Unit survey. Rates of referrals to a postintensive care unit recovery clinic were also observed in relation to the diaries. Although preliminary data did not reveal a significant increase in family satisfaction, the surveys provided important staff feedback. The diaries fostered feelings of compassion and caring as well as built trust between staff and family members of intensive care unit patients. The diaries increased referrals to the postintensive care unit recovery clinic. ©2017 American Association of Critical-Care Nurses.

Patterns of antibacterials use in intensive care units.

PubMed

Santos, Edilson Floriano Dos; Lauria-Pires, Liana

2010-06-01

To know and compare the patterns of antimicrobials use in intensive care units (ICUs) based on the Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) system. a prospective cohort study was conducted in three medical-surgical intensive care units, two of them in public hospitals and one in a private hospital. Simple random, independent samples of patients admitted from 10/2004 to 09/2005 to the selected intensive care units were used. The antibiotics use was assessed using the ATC/DDD system. The amount of antibacterials used in each intensive care unit, in grams, was transformed in daily defined dose (DDD). The number of DDDs was divided by the number of patient-days, multiplied by one thousand, to obtain the average density of consumption (DC) per thousand patient-days (DDD1000). 1,728 patients-days and 2,918.6 DDDs were examined in the three intensive care units, corresponding to an average density of consumption of 1,689.0 DDD1000. The median number of DDDs of antibiotics use in the public hospitals’ intensive care units was significantly higher (p=0.002) versus the private hospital’s intensive care unit. The consumption of antibiotics in the private hospital’s intensive care unit (DC=2,191.7 DDD1000) was significantly higher (p<0.001) versus the intensive care units of public hospitals (1,499.5 DDD1000). The most used antibiotics groups in the three intensive care units were 3rd generation cephalosporins, penicillins/betalactamases inhibitors, carbapenems and fluorquinolones. The pattern of antibiotics use in the three examined intensive care units was not uniform. The private hospital’s intensive care unit used a significantly larger amount versus the public hospitals’ intensive care units. Nevertheless, the most used antibiotics groups were similar in the three intensive care units.

Gaining information about home visits in primary care: methodological issues from a feasibility study

PubMed Central

2014-01-01

Background Home visits are part of general practice work in Germany. Within the context of an expanding elderly population and a decreasing number of general practitioner (GPs), open questions regarding the organisation and adequacy of GPs’ care in immobile patients remain. To answer these questions, we will conduct a representative primary data collection concerning contents and organisation of GPs’ home visits in 2014. Because this study will require considerable efforts for documentation and thus substantial involvement by participating GPs, we conducted a pilot study to see whether such a study design was feasible. Methods We used a mixed methods design with two study arms in a sample of teaching GPs of the University Halle. The quantitative arm evaluates participating GPs and documentation of home visits. The qualitative arm focuses on reasons for non-participation for GPs who declined to take part in the pilot study. Results Our study confirms previously observed reasons for non-response of GPs in the particular setting of home visits including lack of time and/or interest. In contrast to previous findings, monetary incentives were not crucial for GPs participation. Several factors influenced the documentation rate of home visits and resulted in a discrepancy between the numbers of home visits documented versus those actually conducted. The most frequently reported problem was related to obtaining patient consent, especially when patients were unable to provide informed consent due to cognitive deficits. Conclusions The results of our feasibility study provide evidence for improvement of the study design and study instruments to effectively conduct a documentation-intensive study of GPs doing home visits. Improvement of instructions and questionnaire regarding time variables and assessment of the need for home visits will be carried out to increase the reliability of future data. One particularly important methodological issue yet to be resolved is how to increase the representativeness of home visit care by including the homebound patient population that is unable to provide informed consent. PMID:24884460

[Antibiotics in the critically ill].

PubMed

Kolak, Radmila R

2010-01-01

Antibiotics are one the most common therapies administered in the intensive care unit setting. This review outlines the strategy for optimal use of antimicrobial agents in the critically ill. In severely ill patients, empirical antimicrobial therapy should be used when a suspected infection may impair the outcome. It is necessary to collect microbiological documentation before initiating empirical antimicrobial therapy. In addition to antimicrobial therapy, it is recommended to control a focus of infection and to modify factors that promote microbial growth or impair the host's antimicrobial defence. A judicious choice of antimicrobial therapy should be based on the host characteristics, the site of injection, the local ecology, and the pharmacokinetics/pharmacodynamics of antibiotics. This means treating empirically with broad-spectrum antimicrobials as soon as possible and narrowing the spectrum once the organism is identified (de-escalation), and limiting duration of therapy to the minimum effective period. Despite theoretical advantages, a combined antibiotic therapy is nor more effective than a mono-therapy in curing infections in most clinical trials involving intensive care patients. Nevertheless, textbooks and guidelines recommend a combination for specific pathogens and for infections commonly caused by these pathogens. Avoiding unnecessary antibiotic use and optimizing the administration of antimicrobial agents will improve patient outcomes while minimizing risks for the development of bacterial resistance. It is important to note that each intensive care unit should have a program in place which monitors antibiotic utilisation and its effectiveness. Only in this way can the impact of interventions aimed at improving antibiotic use be evaluated at the local level.

Nosocomial infections and resistance pattern of common bacterial isolates in an intensive care unit of a tertiary hospital in Nigeria: A 4-year review.

PubMed

Iliyasu, Garba; Daiyab, Farouq Muhammad; Tiamiyu, Abdulwasiu Bolaji; Abubakar, Salisu; Habib, Zaiyad Garba; Sarki, Adamu Muhammad; Habib, Abdulrazaq Garba

2016-08-01

Infection is a major determinant of clinical outcome among patients in the intensive care unit. However, these data are lacking in most developing countries; hence, we set out to describe the profile of nosocomial infection in one of the major tertiary hospitals in northern Nigeria. Case records of patients who were admitted into the intensive care unit over a 4-year period were retrospectively reviewed. A preformed questionnaire was administered, and data on clinical and microbiological profile of patients with documented infection were obtained. Eighty-our episodes of nosocomial infections were identified in 76 patients. Road traffic accident (29/76, 38.2%) was the leading cause of admission. The most common infections were skin and soft tissue infections (30/84, 35.7%) followed by urinary tract infection (23/84, 27.4%). The most frequent isolates were Staphylococcus aureus (35/84, 41.7%), Klebsiella pneumoniae (18/84, 21.4%), and Escherichia coli (13/84, 15.5%). High rate of resistance to cloxacillin (19/35, 54.3%) and cotrimoxazole (17/26, 65.4%) was noted among the S aureus isolates. All the Enterobacteriaceae isolates were susceptible to meropenem, whereas resistance rate to ceftriaxone was high (E coli, 55.6%; K pneumoniae, 71.4%; Proteus spp, 50%). Infection control practice and measures to curtail the emergence of antimicrobial resistance need to be improved. Copyright © 2016 Elsevier Inc. All rights reserved.

Who has life-sustaining therapy withdrawn after injury?

PubMed

Watch, Libby S; Saxton-Daniels, Stephanie; Schermer, Carol R

2005-12-01

Trauma scoring systems have been developed to help surgeons predict who will die after injury. However, some patients may not actually die of their injuries but may undergo withdrawal of life-sustaining therapy (WLST). The goal of this study was to determine which factors were associated with WLST among older patients who died. We hypothesized that patients with comorbid illnesses, higher injury severity scores (ISS), complications, and existing advanced directives (AD) would be more likely to have WLST and that patients having WLST would receive more medication for symptom relief in the 24 hours before death. Data were collected via a retrospective chart review of patients age 55 years and older admitted to the intensive care unit after injury who subsequently died. In addition to demographic and injury information, documentation of family discussions regarding care wishes and formal ADs were evaluated. Patients dying despite curative attempts were compared with those who died after WLST by Student's t test and chi test where appropriate. In a 3-year period, of 330 patients age 55 and older admitted to the intensive care unit, 66 (20%) died. Complete records were available for 64 patients. More than half of those who died (n = 35, 54.7%) had WLST. ADs were available for 15 patients (23.4%), and 11 (17.2%) patients had expressed to their families desires to not undergo aggressive curative care. Family discussions were documented for 50 (78%) cases. Comorbid illnesses were present in 46 (71.9%) patients and 35 (54.7%) developed at least one complication. Among people with ADs, 73% had WLST versus 49% of people without ADs (p = 0.09). WLST was independent of comorbid illnesses (p = 0.3), complications (p = 0.8), age (p = 0.5), and ISS (p = 0.2). Patients for whom there was documentation of a family discussion were more likely to have WLST than those without (91.4% versus 62.1%, p = 0.005). Morphine and benzodiazepine dosing in the 24 hours preceding death were greater in the WLST group than the curative therapy group (p = 0.02 and p = 0.05, respectively). Expected associations with WLST such as age, ISS, comorbidities, and complications were not present in this population. Although trends may exist regarding patient wishes and ADs, larger studies are needed to corroborate these findings. Given the percentage of patients having supportive care withdrawn, trauma registries and scoring systems should include WLST.

Sustainability of protocolized handover of pediatric cardiac surgery patients to the intensive care unit.

PubMed

Chenault, Kristin; Moga, Michael-Alice; Shin, Minah; Petersen, Emily; Backer, Carl; De Oliveira, Gildasio S; Suresh, Santhanam

2016-05-01

Transfer of patient care among clinicians (handovers) is a common source of medical errors. While the immediate efficacy of these initiatives is well documented, sustainability of practice changes that results in better processes of care is largely understudied. The objective of the current investigation was to evaluate the sustainability of a protocolized handover process in pediatric patients from the operating room after cardiac surgery to the intensive care unit. This was a prospective study with direct observation assessment of handover performance conducted in the cardiac ICU (CICU) of a free-standing, tertiary care children's hospital in the United States. Patient transitions from the operating room to the CICU, including the verbal handoff, were directly observed by a single independent observer in all phases of the study. A checklist of key elements identified errors classified as: (1) technical, (2) information omissions, and (3) realized errors. Total number of errors was compared across the different times of the study (preintervention, postintervention, and the current sustainability phase). A total of 119 handovers were studied: 41 preintervention, 38 postintervention, and 40 in the current sustainability phase. The median [Interquartile range (IQR)] number of technical errors was significantly reduced in the sustainability phase compared to the preintervention and postintervention phase, 2 (1-3), 6 (5-7), and 2.5 (2-4), respectively P = 0.0001. Similarly, the median (IQR) number of verbal information omissions was also significantly reduced in the sustainability phase compared to the preintervention and postintervention phases, 1 (1-1), 4 (3-5) and 2 (1-3), respectively. We demonstrate sustainability of an improved handover process using a checklist in children being transferred to the intensive care unit after cardiac surgery. Standardized handover processes can be a sustainable strategy to improve patient safety after pediatric cardiac surgery. © 2016 John Wiley & Sons Ltd.

Understanding the experience of women admitted to a psychiatric hospital in Sydney with psychosis or mania following childbirth after World War II (1945-1955).

PubMed

Jefferies, Diana; Duff, Margaret; Nicholls, Daniel

2018-04-01

In the present study, we investigated a unique set of historical health-care records of women admitted to a psychiatric hospital in Sydney, Australia with a diagnosis of psychosis or mania after childbirth in the post-World War II (WWII) period, from 1945 to 1955. This research is part of a larger project examining how the descriptions of these women documented in the health-care records from 1885 to 1975 affected their treatment and the outcome of their admission. In the present paper, we report on the findings from an intensive examination of the post WWII documents. Eighteen health-care records from a psychiatric facility (Gladesville Hospital) were identified from admission registers housed in the State Records Office of New South Wales in 2014. Although seven records had been destroyed, 11 were transcribed verbatim. The records contain demographic information; descriptions of the women's signs and symptoms on admission; and information about the women before, during, and after their admission found in letters from relatives or medical staff. A content analysis of admission information showed how the women were described by health-care professionals, but a textual analysis of the records revealed that there were other factors that could have contributed to the women's condition, which might not have been taken into consideration when treatment and care were devised. The present study demonstrates the value of investigating historical health-care records to understand how prevailing attitudes and practices might affect diagnosis and treatment. © 2017 Australian College of Mental Health Nurses Inc.

Online guideline assist in intensive care medicine--is the login-authentication a sufficient trigger for reminders?

PubMed

Röhrig, Rainer; Meister, Markus; Michel-Backofen, Achim; Sedlmayr, Martin; Uphus, Dirk; Katzer, Christian; Rose, Thomas

2006-01-01

Rising cost pressure due to the implementation of the DRG-System and quality assurance lead to an increased use of therapy standards and standard operating procedures (SOPs) in intensive care medicine. The intention of the German Scientific Society supported project "OLGA" (Online Guideline Assist) is to develop a prototype of a knowledge based system supporting physicians of an intensive care unit in recognizing the indication for and selecting a specific guideline or SOP. While the response of the prototype on user entries can be displayed as a signal on the used workstation itself, the location and time for a reminder of scheduled or missed procedures or reactions to imported information is a difficult issue. One possible approach to this task is the display of non acknowledged reminders or recommendations while logging on to a system. The objective of this study is to analyse user behaviour of the physicians working on the surgical intensive care unit to decide whether the login authentication is a sufficient trigger for clinical reminding. The surgical intensive care unit examined in this study comprises 14 beds. Medical care is provided by physicians working in shifts 24 hours a day, 7 days a week, with two anaesthetists at a time and an additional senior consultant during daytime. The entire documentation (examinations, medication, orders, care) is performed using the patient data management system ICUData. The authentication process of the physicians was logged and analysed. Throughout the observation period from December 13th 2005 to January 11th 2006 3563 physician logins were counted in total. The mean span between logins was in 11.3 minutes (SD 14.4), the median 7 minutes. The 75% centile was 14 minutes, the 95% centile 38 min. Intervals greater than 60 minutes occurred in 75%, and greater than 90 minutes in 25% of the days. It seems reasonable that reminders sent during authentication are able to enforce workflow compliance. It is possible to send notifications caused by external events to the physician depending on the importance of the event. Serious events with high urgency should be reliably passed using wireless pager or handheld technology. It seems that after the implementation of the prototype guideline assist further investigation is needed to monitor changes in authentication behaviour and reactions to the guideline advisory. This is also required to investigate the influence of unit's size, medical specialty and actual ward workload.

Managing social awkwardness when caring for morbidly obese patients in intensive care: A focused ethnography.

PubMed

Hales, Caz; de Vries, Kay; Coombs, Maureen

2016-06-01

Critically ill morbidly obese patients pose considerable healthcare delivery and resource utilisation challenges in the intensive care setting. These are resultant from specific physiological responses to critical illness in this population and the nature of the interventional therapies used in the intensive care environment. An additional challenge arises for this population when considering the social stigma that is attached to being obese. Intensive care staff therefore not only attend to the physical and care needs of the critically ill morbidly obese patient but also navigate, both personally and professionally, the social terrain of stigma when providing care. To explore the culture and influences on doctors and nurses within the intensive care setting when caring for critically ill morbidly obese patients. A focused ethnographic approach was adopted to elicit the 'situated' experiences of caring for critically ill morbidly obese patients from the perspectives of intensive care staff. Participant observation of care practices and interviews with intensive care staff were undertaken over a four month period. Analysis was conducted using constant comparison technique to compare incidents applicable to each theme. An 18 bedded tertiary intensive care unit in New Zealand. Sixty-seven intensive care nurses and 13 intensive care doctors involved with the care and management of seven critically ill patients with a body mass index ≥40kg/m(2). Interactions between intensive care staff and morbidly obese patients were challenging due to the social stigma surrounding obesity. Social awkwardness and managing socially awkward moments were evident when caring for morbidly obese patients. Intensive care staff used strategies of face-work and mutual pretence to alleviate feelings of discomfort when engaged in aspects of care and caring. This was a strategy used to prevent embarrassment and distress for both the patients and staff. This study has brought new understandings about intensive care situations where social awkwardness occurs in the context of obesity and care practices, and of the performances and behaviours of staff in managing the social awkwardness of fat-stigma during care situations. Copyright © 2016. Published by Elsevier Ltd.

XML and its impact on content and structure in electronic health care documents.

PubMed Central

Sokolowski, R.; Dudeck, J.

1999-01-01

Worldwide information networks have the requirement that electronic documents must be easily accessible, portable, flexible and system-independent. With the development of XML (eXtensible Markup Language), the future of electronic documents, health care informatics and the Web itself are about to change. The intent of the recently formed ASTM E31.25 subcommittee, "XML DTDs for Health Care", is to develop standard electronic document representations of paper-based health care documents and forms. A goal of the subcommittee is to work together to enhance existing levels of interoperability among the various XML/SGML standardization efforts, products and systems in health care. The ASTM E31.25 subcommittee uses common practices and software standards to develop the implementation recommendations for XML documents in health care. The implementation recommendations are being developed to standardize the many different structures of documents. These recommendations are in the form of a set of standard DTDs, or document type definitions that match the electronic document requirements in the health care industry. This paper discusses recent efforts of the ASTM E31.25 subcommittee. PMID:10566338

The refusal of treatment: living wills and the current law in the UK.

PubMed

Dimond, Bridgit

David Browne was suffering from motor neurone disease and was anxious to ensure that as his disease progressed and he ceased to be mentally capacitated he would not be given artificial feeding and ventilation. He therefore arranged to draw up a living will in which he gave an advanced refusal of such treatments. The document was duly signed and witnessed. Only 3 months after signing the living will he was severely injured in a road accident and brought into hospital unconscious. He was carrying his living will in his pocket. The doctors were concerned that if they operated and he required ventilation in intensive care, would the living will prevent their providing such treatment and care? What is the law?

A stepped-wedge evaluation of an initiative to spread the collaborative care model for depression in primary care.

PubMed

Solberg, Leif I; Crain, A Lauren; Maciosek, Michael V; Unützer, Jürgen; Ohnsorg, Kris A; Beck, Arne; Rubenstein, Lisa; Whitebird, Robin R; Rossom, Rebecca C; Pietruszewski, Pamela B; Crabtree, Benjamin F; Joslyn, Kenneth; Van de Ven, Andrew; Glasgow, Russell E

2015-09-01

Scale-up and spread of evidence-based practices is one of the most important challenges facing health care. We tested whether a statewide initiative, Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND), to implement the collaborative care model for depression in 75 primary care clinics resulted in patient outcome improvements corresponding to those reported in randomized controlled trials. Health plans provided a new monthly payment to participating clinics after a 6-month intensive training program with ongoing data submission, networking, and consultation. Implementation was staggered, with 5 sequences of 10 to 40 clinics every 6 months. Payers provided weekly contact information for members from participating clinics who were filling antidepressant prescriptions, and we conducted baseline and 6-month surveys of 1,578 patients about their care and outcomes. There were 466 patients in DIAMOND clinics who received usual care before implementation (UCB), 559 who received usual care in DIAMOND clinics after implementation (UCA), 245 who received DIAMOND care after implementation (DCA), and 308 who received usual care in comparison clinics (UC). Patients who received DIAMOND care after implementation reported more collaborative care depression services than the 3 comparison groups (10.9 vs 6.4-6.7, on a scale of 0 of 14, where higher numbers indicate more services; P <.001) and more satisfaction with their care (4.0 vs 3.4 on a scale 1 to 5, in which higher scores indicate higher satisfaction; P ≤.001). Depression remission rates, however, were not significantly different among the 4 groups (36.4% DCA vs 35.8% UCB, 35.0% UCA, 33.9% UC; P = .94). Despite the incentive of a supporting payment change and intensive training and support for clinics volunteering to participate, no difference in depression outcomes was documented. Specific unmeasured actions present in trials but not present in these clinics may be critical for successful outcome improvement. © 2015 Annals of Family Medicine, Inc.

Medicare intensive care unit use: analysis of incidence, cost, and payment.

PubMed

Cooper, Liesl M; Linde-Zwirble, Walter T

2004-11-01

To determine the incidence, cost, and payment for intensive care unit services among Medicare beneficiaries. Retrospective observational database cohort study. All nonfederal hospitals with intensive care unit beds (n = 5003) paid through the inpatient prospective payment system (IPPS). We used all fiscal year 2000 Medicare IPPS hospitalizations with consistent payment information (n = 10,657,587). None. We examined the distribution of cost and payments overall, by hospital type, and by diagnosis related group. Intensive care was used in 2,353,208 cases (21.1%). The overall incidence was 59.8 cases per thousand beneficiaries in the aged (65+) population, increasing with age from 36.2 (65-69) to 91.6 (85+). Intensive care unit patients cost nearly three times floor patients (4,135 dollars vs. 5,571 dollars), with two thirds of costs associated with the intensive care unit portion of the stay, 2,278 dollars per intensive care unit day. However, intensive care unit cases were paid at a rate only twice floor cases (11,704 dollars vs. 5,835 dollars). Only 83% of costs were paid for intensive care unit patients, compared with 105% for floor patients, generating a 5.8 billion dollars loss to hospitals when intensive care unit care is required. There was a linear association between the percent intensive care unit in a diagnosis related group and the percent paid, with payment >90% of cost only in diagnosis related groups with >/=60% intensive care unit cases. We found that teaching hospitals were better paid than nonteaching hospitals (87% vs. 78% of costs, respectively), but this was only due to indirect medical education payments. Intensive care is common, expensive, and poorly paid in the Medicare population. Few diagnosis related groups have a large enough intensive care unit population to ensure adequate payment. Additional diagnosis related groups for conditions common to the intensive care unit would improve payment and enable incentives for efficiency.

Conflict in the intensive care unit: Nursing advocacy and surgical agency.

PubMed

Pecanac, Kristen E; Schwarze, Margaret L

2018-02-01

Nurses and surgeons may experience intra-team conflict during decision making about the use of postoperative life-sustaining treatment in the intensive care unit due to their perceptions of professional roles and responsibilities. Nurses have a sense of advocacy-a responsibility to support the patient's best interest; surgeons have a sense of agency-a responsibility to keep the patient alive. The objectives were to (1) describe the discourse surrounding the responsibilities of nurses and surgeons, as "advocates" and "agents," and (2) apply these findings to determine how differences in role responsibilities could foster conflict during decision making about postoperative life-sustaining treatment in the intensive care unit. Articles, books, and professional documents were explored to obtain descriptions of nurses' and surgeons' responsibilities to their patients. Using discourse analysis, responsibilities were grouped into themes and then compared for potential for conflict. Ethical considerations: No data were collected from human participants and ethical review was not required. The texts were analyzed by a surgeon and a nurse to minimize profession-centric biases. Four themes in nursing discourse were identified: responsibility to support patient autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as an intermediary between the physician and the patient, and the responsibility to support the well-being of the patient. Three themes in surgery discourse were identified personal responsibility for the patient's outcome, commitment to patient survival, and the responsibility to prevent harm to the patient from surgery. These responsibilities may contribute to conflict because each profession is working toward different goals and each believes they know what is best for the patient. It is not clear from the existing literature that either profession understands each other's responsibilities. Interventions that improve understanding of each profession's responsibilities may be helpful to reduce intra-team conflict in the intensive care unit.

Technology--an actor in the ICU: a study in workplace research tradition.

PubMed

Wikström, Ann-Charlott; Larsson, Ullabeth Sätterlund

2004-07-01

The present study focuses on human-machine interaction in an intensive care unit in the West of Sweden. The aim of the present study was to explore how technology intervenes and challenges the ICU staff's knowing in practice. THEORETICAL PERSPECTIVE: The study's theoretical starting point draws on workplace research tradition. Workplace studies encompass the interaction between the actors' situated activities and the technological tools that make their activities possible. Fieldwork or in situ studies of everyday practice in an intensive care unit documented in written field notes constituted the data. The findings show first how technology intervenes in the division of labour when the taken-for-granted "old" everyday practice is disrupted when a new machine intervenes in the morning's work; secondly, it reveal how technology challenges practical knowing and thirdly, it shows how technology reformulates practice. Staff members' awareness of routine problems is often connected to the ability to see, which is always related to cultural/contextual competence. It is concluded that it is not talk alone that helps the caregivers to "(dis)solve" the problems. The ability to see the problems, the work environment and to find the relevant supporting tools for "(dis)solving" the routine problems is also crucial. But it is not possible to say that it is the skillful work of humans that solve problems, nor do we claim it is the tools that do so. Humans and tools are interwoven in the problem-solving process. Relevance to clinical practice. Routine problems in the intensive care unit are not "(dis)solved" through the cognitive work of individual staff members alone. Problems are also "(dis)solved" jointly with other staff members. Staff members "borrow" the knowing from each other and problems are re-represented through communication. The knowing has to be distributed among the intensive care unit staff to make the everyday work flexible.

Comprehensiveness and humanization of nursing care management in the Intensive Care Unit.

PubMed

Medeiros, Adriane Calvetti de; Siqueira, Hedi Crecencia Heckler de; Zamberlan, Claudia; Cecagno, Diana; Nunes, Simone Dos Santos; Thurow, Mara Regina Bergmann

2016-01-01

Identifying the elements that promote comprehensiveness and humanization of nursing care management in the Intensive Care Unit, with an ecosystemic approach. A documentary qualitative study. The method of documentary analysis was used for data analysis. Four pre-established categories were identified - Technical; Organizational; Technological; and Humanizing Dimensions. Data resulted in forming two sub-categories that integrate the humanizing dimension category, namely 'Comprehensiveness in healthcare actions' and 'Integrating processes and promoters of humanization,' bringing forth implications and challenges in forms of managing health work processes, enabling organizational, structural and managerial changes to the provided healthcare. It was considered that all structural elements in managing nursing care with a focus on the needs of users should be in line with public policies and the principles of comprehensiveness and humanization, thus possessing strong potential for transforming health practices. Identificar os elementos capazes de promover a integralidade e a humanização na gestão do cuidado de enfermagem na Unidade de Terapia Intensiva, com enfoque ecossistêmico. Pesquisa documental, de natureza qualitativa. Para a análise dos dados utilizou-se do método da análise documental. SForam identificadas quatro categorias preestabelecidas ‒ Dimensões: Técnica; Organizacional; Tecnológica e Humanizadora. Os dados resultantes das duas subcategorias que integraram a categoria Dimensão Humanizadora, Integralidade nas ações do cuidado e Processos integradores e promotores de humanização, trazem implicações e desafios nos modos de gerir os processos de trabalho em saúde, o que possibilita transformações organizacionais, estruturais e gerenciais na produção do cuidado. Considera-se que na gestão do cuidado de enfermagem todos os elementos estruturantes, com enfoque nas necessidades dos usuários, devem estar em consonância com as políticas públicas e os princípios da integralidade e da humanização e possuir forte potencial para a transformação das práticas em saúde.

KernPaeP - a web-based pediatric palliative documentation system for home care.

PubMed

Hartz, Tobias; Verst, Hendrik; Ueckert, Frank

2009-01-01

KernPaeP is a new web-based on- and offline documentation system, which has been developed for pediatric palliative care-teams supporting patient documentation and communication among health care professionals. It provides a reliable system making fast and secure home care documentation possible. KernPaeP is accessible online by registered users using any web-browser. Home care teams use an offline version of KernPaeP running on a netbook for patient documentation on site. Identifying and medical patient data are strictly separated and stored on two database servers. The system offers a stable, enhanced two-way algorithm for synchronization between the offline component and the central database servers. KernPaeP is implemented meeting highest security standards while still maintaining high usability. The web-based documentation system allows ubiquitous and immediate access to patient data. Sumptuous paper work is replaced by secure and comprehensive electronic documentation. KernPaeP helps saving time and improving the quality of documentation. Due to development in close cooperation with pediatric palliative professionals, KernPaeP fulfils the broad needs of home-care documentation. The technique of web-based online and offline documentation is in general applicable for arbitrary home care scenarios.

Innovation and Technology: Electronic Intensive Care Unit Diaries.

PubMed

Scruth, Elizabeth A; Oveisi, Nazanin; Liu, Vincent

2017-01-01

Hospitalization in the intensive care unit can be a stressful time for patients and their family members. Patients' family members often have difficulty processing all of the information that is given to them. Therefore, an intensive care unit diary can serve as a conduit for synthesizing information, maintaining connection with patients, and maintaining a connection with family members outside the intensive care unit. Paper intensive care unit diaries have been used outside the United States for many years. This article explores the development of an electronic intensive care unit diary using a rapid prototyping model to accelerate the process. Initial results of design testing demonstrate that it is feasible, useful, and desirable to consider the implementation of electronic intensive care unit diaries for patients at risk for post-intensive care syndrome. ©2017 American Association of Critical-Care Nurses.

In their own words: Patients and families define high-quality palliative care in the intensive care unit*

PubMed Central

Nelson, Judith E.; Puntillo, Kathleen A.; Pronovost, Peter J.; Walker, Amy S.; McAdam, Jennifer L.; Ilaoa, Debra; Penrod, Joan

2011-01-01

Objective Although the majority of hospital deaths occur in the intensive care unit and virtually all critically ill patients and their families have palliative needs, we know little about how patients and families, the most important “stakeholders,” define high-quality intensive care unit palliative care. We conducted this study to obtain their views on important domains of this care. Design Qualitative study using focus groups facilitated by a single physician. Setting A 20-bed general intensive care unit in a 382-bed community hospital in Oklahoma; 24-bed medical–surgical intensive care unit in a 377-bed tertiary, university hospital in urban California; and eight-bed medical intensive care unit in a 311-bed Veterans’ Affairs hospital in a northeastern city. Patients Randomly-selected patients with intensive care unit length of stay ≥5 days in 2007 to 2008 who survived the intensive care unit, families of survivors, and families of patients who died in the intensive care unit. Interventions None. Measurements and Main Results Focus group facilitator used open-ended questions and scripted probes from a written guide. Three investigators independently coded meeting transcripts, achieving consensus on themes. From 48 subjects (15 patients, 33 family members) in nine focus groups across three sites, a shared definition of high-quality intensive care unit palliative care emerged: timely, clear, and compassionate communication by clinicians; clinical decision-making focused on patients’ preferences, goals, and values; patient care maintaining comfort, dignity, and personhood; and family care with open access and proximity to patients, interdisciplinary support in the intensive care unit, and bereavement care for families of patients who died. Participants also endorsed specific processes to operationalize the care they considered important. Conclusions Efforts to improve intensive care unit palliative care quality should focus on domains and processes that are most valued by critically ill patients and their families, among whom we found broad agreement in a diverse sample. Measures of quality and effective interventions exist to improve care in domains that are important to intensive care unit patients and families. PMID:20198726

Practice variation in the transfer of premature infants from incubators to open cots in Australian and New Zealand neonatal nurseries: results of an electronic survey.

PubMed

New, Karen; Bogossian, Fiona; East, Christine; Davies, Mark William

2010-06-01

The incubator environment is essential for optimal physiological functioning and development of the premature infant but the infant is ultimately required to make a successful transfer from incubator to open cot in order to be discharged from hospital. Criteria for transfer lack a systematic approach because no clear, specific guideline predominates in clinical practice. Practice variation exists between continents, regions and nurseries in the same countries, but there is no recent review of current practices utilised for transferring premature infants from incubators to open cots. To document current practice for transferring premature infants to open cots in neonatal nurseries. A descriptive, cross-sectional survey. Twenty-two neonatal intensive care units and fifty-six high dependency special care baby units located in public hospitals in Australia and New Zealand. A sample of 78 key clinical nursing leaders (nurse unit managers, clinical nurse consultants or clinical nurse specialists) within neonatal nurseries identified through email or telephone contact. Data were collected using a web-based survey on practice, decision-making and strategies utilised for transferring premature infants from incubators to open cots. Descriptive statistics (frequencies and crosstabs) were used to analyse data. Comparisons between groups were tested for statistical significance using Chi-squared or Fisher's exact test. Significant practice variation between countries was found for only one variable, nursing infants clothed (p=0.011). Processes and practices undertaken similarly in both countries include use of incubator air control mode, current weight criterion, thermal challenging, single-walled incubators and heated mattress systems. Practice variation was significant between neonatal intensive care units and special care baby units for weight range (p=0.005), evidence-based practice (p=0.004), historical nursery practice (p=0.029) and incubator air control mode (p=0.001). Differences in these variables were also found between nurseries in metropolitan and rural locations. Practice variation exists however; many practices are uniformly performed throughout neonatal nurseries in Australian and New Zealand. Commonality was seen between countries and in nurseries with a neonatal intensive care unit. Variation was significant between neonatal intensive care units and special care baby units and nurseries in metropolitan and rural locations. (c) 2009 Elsevier Ltd. All rights reserved.

MALDI-TOF MS typing of a nosocomial methicillin-resistant Staphylococcus aureus outbreak in a neonatal intensive care unit.

PubMed

Steensels, Deborah; Deplano, Ariane; Denis, Olivier; Simon, Anne; Verroken, Alexia

2017-08-01

The early detection of a methicillin-resistant Staphylococcus aureus (MRSA) outbreak is decisive to control its spread and rapidly initiate adequate infection control measures. Therefore, prompt determination of epidemiologic relatedness of clinical MRSA isolates is essential. Genetic typing methods have a high discriminatory power but their availability remains restricted. In this study, we aimed to challenge matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) as a typing tool of a nosocomial MRSA outbreak in a neonatal intensive care unit. Over a 2-year period, 15 MRSA isolates were recovered from patients (n = 14) and health care workers (n = 1) at the neonatal intensive care unit. Five reference strains were included for comparison. Identification was performed by MALDI-TOF MS and susceptibility profiles determined by automated broth microdilution. Typing analysis by MALDI-TOF MS included mean spectrum profiles and subsequent dendrogram creation using BioNumerics software. Results were compared with spa typing and pulsed-field gel electrophoresis (PFGE). Our study showed good concordance (93%) between PFGE, spa typing, and MALDI-TOF MS for the outbreak-related MRSA strains. MALDI-TOF MS typing showed excellent typeability and discriminatory power but showed poor reproducibility. This study is one of the first to document the potential usefulness of MALDI-TOF MS with standardized data analysis as a typing tool for investigating a nosocomial MRSA outbreak. A concordance of 93% compared to reference typing techniques was observed. However, because of poor reproducibility, long-term follow-up of prospective isolated strains is not practical for routine use. Further studies are needed to confirm our observations.

Effects of Nasal Continuous Positive Airway Pressure and Cannula Use in the Neonatal Intensive Care Unit Setting

PubMed Central

Jatana, Kris R.; Oplatek, Agnes; Stein, Melanie; Phillips, Gary; Kang, D. Richard; Elmaraghy, Charles A.

2013-01-01

Objective To investigate the effects of nasal continuous positive airway pressure (CPAP) and cannula use in the neonatal intensive care unit. Design Cross-sectional study. Setting Tertiary care children’s hospital. Patients One hundred patients (200 nasal cavities), younger than 1 year, who received at least 7 days of nasal CPAP (n = 91) or cannula supplementation (n = 9) in the neonatal intensive care unit. Interventions External nasal examination and anterior nasal endoscopy with photographic documentation. Main Outcome Measures The incidence and characteristics of internal and external nasal findings of patients with nasal CPAP or cannula use. Results Nasal complications were seen in 12 of the 91 patients (13.2%) with at least 7 days of nasal CPAP exposure, while no complications were seen in the 9 patients with nasal cannula use alone. The external nasal finding of columellar necrosis, seen in 5 patients (5.5%), occurred as early as 10 days after nasal CPAP use. Incidence of intranasal findings attributed to CPAP use, in the 182 nostrils examined, included ulceration in 6 nasal cavities (3.3%), granulation in 3 nasal cavities (1.6%), and vestibular stenosis in 4 nasal cavities (2.2%). Intranasal complications were seen as early as 8 to 9 days after nasal CPAP administration. Nasal complications from CPAP were associated with lower Apgar scores at 1 (P = .02) and 5 (P = .06) minutes. Conclusions External or internal complications of nasal CPAP can be relatively frequent (13.2%) and can occur early, and patients with lower Apgar scores may be at higher risk. Close surveillance for potential complications should be considered during nasal CPAP use. PMID:20231649

Principles of Automation for Patient Safety in Intensive Care: Learning From Aviation.

PubMed

Dominiczak, Jason; Khansa, Lara

2018-06-01

The transition away from written documentation and analog methods has opened up the possibility of leveraging data science and analytic techniques to improve health care. In the implementation of data science techniques and methodologies, high-acuity patients in the ICU can particularly benefit. The Principles of Automation for Patient Safety in Intensive Care (PASPIC) framework draws on Billings's principles of human-centered aviation (HCA) automation and helps in identifying the advantages, pitfalls, and unintended consequences of automation in health care. Billings's HCA principles are based on the premise that human operators must remain "in command," so that they are continuously informed and actively involved in all aspects of system operations. In addition, automated systems need to be predictable, simple to train, to learn, and to operate, and must be able to monitor the human operators, and every intelligent system element must know the intent of other intelligent system elements. In applying Billings's HCA principles to the ICU setting, PAPSIC has three key characteristics: (1) integration and better interoperability, (2) multidimensional analysis, and (3) enhanced situation awareness. PAPSIC suggests that health care professionals reduce overreliance on automation and implement "cooperative automation" and that vendors reduce mode errors and embrace interoperability. Much can be learned from the aviation industry in automating the ICU. Because it combines "smart" technology with the necessary controls to withstand unintended consequences, PAPSIC could help ensure more informed decision making in the ICU and better patient care. Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.

Learning to manage vasoactive drugs-A qualitative interview study with critical care nurses.

PubMed

Häggström, Marie; Bergsman, Ann-Christin; Månsson, Ulrika; Holmström, Malin Rising

2017-04-01

Being a nurse in an intensive care unit entails caring for seriously ill patients. Vasoactive drugs are one of the tools that are used to restore adequate circulation. Critical care nurses often manage and administer these potent drugs after medical advice from physicians. To describe the experiences of critical care nurses learning to manage vasoactive drugs, and to highlight the competence required to manage vasoactive drugs. Twelve critical care nurses from three hospitals in Sweden were interviewed. Qualitative content analysis was applied. The theme "becoming proficient requires accuracy, practice and precaution" illustrated how critical care nurses learn to manage vasoactive drugs. Learning included developing cognitive, psychomotor, and effective skills. Sources for knowledge refers to specialist education combined with practical exercises, collegial support, and accessible routine documents. The competence required to manage vasoactive drugs encompassed well-developed safety thinking that included being careful, in control, and communicating failures. Specific skills were required such as titrating doses, being able to analyse and evaluate the technological assessments, adapting to the situation, and staying calm. Learning to manage vasoactive drugs requires a supportive introduction for novices, collegial support, lifelong learning, and a culture of safety. Copyright © 2016 Elsevier Ltd. All rights reserved.

Strange and scary memories of the intensive care unit: a qualitative, longitudinal study inspired by Ricoeur's interpretation theory.

PubMed

Svenningsen, Helle; Egerod, Ingrid; Dreyer, Pia

2016-10-01

To describe the content of former intensive care unit patients' memories of delusions. Intensive care unit patients often have strange and frightening experiences during the critical stage of illness. Earlier studies have provided small-sample in-depth descriptions of patient experiences in intensive care unit, but large-scale studies are also needed to inform intensive care unit follow-up. The study had a qualitative design using phenomenological hermeneutic analysis inspired by Ricoeur's interpretive theory. Patients were assessed with Confusion Assessment Method of the Intensive Care Unit for delirium in intensive care unit, and after discharge, memories of delusions were described by 114 of 325 patients in face-to-face (after two weeks) and telephone interviews (after two and six months) using the Intensive Care Unit Memory Tool. Four themes emerged: the ever-present family, dynamic spaces, surviving challenges and constant motion. Memories of delusions were a vivid mix of fact and fiction, demonstrating dynamic shifts in time, place and motion, but not dependent on the presence of delirium assessed by Confusion Assessment Method of the Intensive Care Unit. Analysis based on Ricoeurian phenomenological hermeneutics provided insights into themes in intensive care unit patients' memories of delusions. More studies are needed to understand the meaning of memories of delusions, the commonality of themes and the association between delusions and delirium after an intensive care unit stay. Understanding patients' memories of delusions is beneficial to nurses caring for patients that are anxious, upset or agitated. It opens a window to the world of the patient who is unable to communicate due to intubation and general weakness. We recommend the provision of nurse-led intensive care unit follow-up enabling patients to describe and discuss their intensive care unit experiences. © 2016 John Wiley & Sons Ltd.

Prevention of bacterial infection in pediatric oncology: what do we know, what can we learn?

PubMed

Alexander, Sarah; Nieder, Michael; Zerr, Danielle M; Fisher, Brian T; Dvorak, Christopher C; Sung, Lillian

2012-07-15

Bacterial sepsis continues to be a leading cause of morbidity and toxic death in children receiving intensive therapy for cancer. Empiric therapy for suspected infections and treatment of documented infections are well-established standards of care. The routine use of prophylactic strategies is much less common in pediatric oncology. This paper will review the current literature on the use and risks of antimicrobial prophylaxis as well as non-pharmacological methods for infection prevention and will address areas in need of further research. Copyright © 2011 Wiley Periodicals, Inc.

Guidelines for the assessment and acceptance of potential brain-dead organ donors

PubMed Central

Westphal, Glauco Adrieno; Garcia, Valter Duro; de Souza, Rafael Lisboa; Franke, Cristiano Augusto; Vieira, Kalinca Daberkow; Birckholz, Viviane Renata Zaclikevis; Machado, Miriam Cristine; de Almeida, Eliana Régia Barbosa; Machado, Fernando Osni; Sardinha, Luiz Antônio da Costa; Wanzuita, Raquel; Silvado, Carlos Eduardo Soares; Costa, Gerson; Braatz, Vera; Caldeira Filho, Milton; Furtado, Rodrigo; Tannous, Luana Alves; de Albuquerque, André Gustavo Neves; Abdala, Edson; Gonçalves, Anderson Ricardo Roman; Pacheco-Moreira, Lúcio Filgueiras; Dias, Fernando Suparregui; Fernandes, Rogério; Giovanni, Frederico Di; de Carvalho, Frederico Bruzzi; Fiorelli, Alfredo; Teixeira, Cassiano; Feijó, Cristiano; Camargo, Spencer Marcantonio; de Oliveira, Neymar Elias; David, André Ibrahim; Prinz, Rafael Augusto Dantas; Herranz, Laura Brasil; de Andrade, Joel

2016-01-01

Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors. PMID:27737418

Changing levels of quiet in an intensive care nursery.

PubMed

Philbin, M Kathleen; Gray, Lincoln

2002-09-01

To document low sound levels, the range and pattern of levels, and the relative effects of operational (staff and equipment generated) and facility (building generated) noise on the acoustic environment of a level III nursery. A quasi-experimental, prospective, longitudinal study of one bed space. Operational noise was reduced through staff behavior change while facility noise was reduced through renovation. Initial noise levels were typical of those in the literature and in recently measured nurseries. About 80% of sound levels were between 62 and 70 dBA. The lowest levels (L(min)) were 60 to 65 dBA. After staff behavior change, L(min) was about 56 dBA although the highest levels (L(max)) remained at 78 to 100 dBA. Levels following renovation were reduced to L(min)s of 47 to 51 dBA and L(max)s of 68 to 84 dBA, perceived as three or four times quieter than initially. Staff behavior as well as the acoustical characteristics of the facility determine the levels of noise and quiet in an intensive care nursery.

Use of donor milk in the neonatal intensive care unit.

PubMed

de Halleux, Virginie; Pieltain, Catherine; Senterre, Thibault; Rigo, Jacques

2017-02-01

Own mother's milk is the first choice in feeding preterm infants and provides multiple short- and long-term benefits. When it is unavailable, donor human milk is recommended as the first alternative. Donor milk undergoes processing (i.e. pasteurization) to reduce bacteriological and viral contaminants but influences its bioactive properties with potentially fewer benefits than raw milk. However, there is no clinical evidence of health benefit of raw compared to pasteurized human milk, and donor milk maintains documented advantages compared to formula. Nutrient content of donor and own mother's milk fails to meet the requirements of preterm infants. Adequate fortification is necessary to provide optimal growth. There are significant challenges in providing donor milk for premature infants; therefore, specific clinical guidelines for human milk banks and donor milk use in the neonatal intensive care unit should be applied and research should focus on innovative solutions to process human milk while preserving its immunological and nutritional components. In addition, milk banks are not the only instrument to collect, process and store donor milk but represent an excellent tool for breastfeeding promotion. Copyright © 2016 Elsevier Ltd. All rights reserved.

Hands-Free Image Capture, Data Tagging and Transfer Using Google Glass: A Pilot Study for Improved Wound Care Management

PubMed Central

Aldaz, Gabriel; Shluzas, Lauren Aquino; Pickham, David; Eris, Ozgur; Sadler, Joel; Joshi, Shantanu; Leifer, Larry

2015-01-01

Chronic wounds, including pressure ulcers, compromise the health of 6.5 million Americans and pose an annual estimated burden of $25 billion to the U.S. health care system. When treating chronic wounds, clinicians must use meticulous documentation to determine wound severity and to monitor healing progress over time. Yet, current wound documentation practices using digital photography are often cumbersome and labor intensive. The process of transferring photos into Electronic Medical Records (EMRs) requires many steps and can take several days. Newer smartphone and tablet-based solutions, such as Epic Haiku, have reduced EMR upload time. However, issues still exist involving patient positioning, image-capture technique, and patient identification. In this paper, we present the development and assessment of the SnapCap System for chronic wound photography. Through leveraging the sensor capabilities of Google Glass, SnapCap enables hands-free digital image capture, and the tagging and transfer of images to a patient’s EMR. In a pilot study with wound care nurses at Stanford Hospital (n=16), we (i) examined feature preferences for hands-free digital image capture and documentation, and (ii) compared SnapCap to the state of the art in digital wound care photography, the Epic Haiku application. We used the Wilcoxon Signed-ranks test to evaluate differences in mean ranks between preference options. Preferred hands-free navigation features include barcode scanning for patient identification, Z(15) = -3.873, p < 0.001, r = 0.71, and double-blinking to take photographs, Z(13) = -3.606, p < 0.001, r = 0.71. In the comparison between SnapCap and Epic Haiku, the SnapCap System was preferred for sterile image-capture technique, Z(16) = -3.873, p < 0.001, r = 0.68. Responses were divided with respect to image quality and overall ease of use. The study’s results have contributed to the future implementation of new features aimed at enhancing mobile hands-free digital photography for chronic wound care. PMID:25902061

A conceptual framework of clinical nursing care in intensive care.

PubMed

da Silva, Rafael Celestino; Ferreira, Márcia de Assunção; Apostolidis, Thémistoklis; Brandão, Marcos Antônio Gomes

2015-01-01

to propose a conceptual framework for clinical nursing care in intensive care. descriptive and qualitative field research, carried out with 21 nurses from an intensive care unit of a federal public hospital. We conducted semi-structured interviews and thematic and lexical content analysis, supported by Alceste software. the characteristics of clinical intensive care emerge from the specialized knowledge of the interaction, the work context, types of patients and nurses characteristic of the intensive care and care frameworks. the conceptual framework of the clinic's intensive care articulates elements characteristic of the dynamics of this scenario: objective elements regarding technology and attention to equipment and subjective elements related to human interaction, specific of nursing care, countering criticism based on dehumanization.

Caretaking as articulation work: the effects of taking up responsibility for a child with asthma on labor force participation.

PubMed

Timmermans, Stefan; Freidin, Betina

2007-10-01

A well-established quantitative literature has documented the financial toll for women's caretaking. Still, we do not know much about the process by which women end up taking on an extensive caretaking role and what they do on a daily basis. Based on in-depth interviews with a convenience sample of fifty caretakers of school aged children with asthma and nine health professionals in the USA, this study examines how health professionals socialize mothers into an intensive caretaking role for their children with asthma, how mothers negotiated and perform that role, and the impact of care work on their labor force participation. Care providers assign broad caretaking tasks that require further articulation work to get the job done. Although mothers care for their children in varied ways, caring for a child with a chronic disease remains a time-consuming activity. Mothers pay a price for the indeterminate nature of articulation work by scaling back their involvement in the paid labor force.

78 FR 20503 - Energy Conservation Program: Availability of the Interim Technical Support Document for High...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-05

... Conservation Program: Availability of the Interim Technical Support Document for High-Intensity Discharge Lamps... high-intensity discharge (HID) lamps energy conservation standards in the Federal Register. This... interim analysis for high- intensity discharge lamps energy conservation standards. The notice provided...

Variation in critical care services across North America and Western Europe.

PubMed

Wunsch, Hannah; Angus, Derek C; Harrison, David A; Collange, Olivier; Fowler, Robert; Hoste, Eric A J; de Keizer, Nicolette F; Kersten, Alexander; Linde-Zwirble, Walter T; Sandiumenge, Alberto; Rowan, Kathryn M

2008-10-01

Critical care represents a large percentage of healthcare spending in developed countries. Yet, little is known regarding international variation in critical care services. We sought to understand differences in critical care delivery by comparing data on the distribution of services in eight countries. Retrospective review of existing national administrative data. We identified sources of data in each country to provide information on acute care hospitals and beds, intensive care units and beds, intensive care admissions, and definitions of intensive care beds. Data were all referenced and from as close to 2005 as possible. United States, France, United Kingdom, Canada, Belgium, Germany, The Netherlands, and Spain. Not available. None. No standard definition existed for acute care hospital or intensive care unit beds across countries. Hospital beds varied three-fold from 221/100,000 population in the United States to 593/100,000 in Germany. Adult intensive care unit beds also ranged seven-fold from 3.3/100,000 population in the United Kingdom to 24.0/100,000 in Germany. Volume of intensive care unit admissions per year varied ten-fold from 216/100,000 population in the United Kingdom to 2353/100,000 in Germany. The ratio of intensive care unit beds to hospital beds was highly correlated across all countries except the United States (r = .90). There was minimal correlation between the number of intensive care unit beds per capita and health care spending per capita (r = .45), but high inverse correlation between intensive care unit beds and hospital mortality for intensive care unit patients across countries (r = -.82). Absolute critical care services vary dramatically between countries with wide differences in both numbers of beds and volume of admissions. The number of intensive care unit beds per capita is not strongly correlated with overall health expenditure, but does correlate strongly with mortality. These findings demonstrate the need for critical care data from all countries, as they are essential for interpretation of studies, and policy decisions regarding critical care services.

Maintaining patient dignity in intensive care settings.

PubMed

Turnock, C; Kelleher, M

2001-06-01

Maintenance of the dignity of intensive care unit (ICU) patients, particularly minimizing exposure of genitalia, may be problematic. The aim of the study was to develop strategies to maximize the dignity of ICU patients using an action research methodology. The first stage assessed current practice through 62 hours of non-participant observation of patient care. Patient dignity was maintained in almost one-third of observed cases. However, more intimate areas such as bosom and genitalia were exposed in over 40% of the incidents. Whilst screens were fully used in over one-third of exposure incidents, full screening did not occur for all or part of the remaining incidents. Significant factors (P < 0.05) influencing exposure included gender and age. Female and younger (< 60 years) patients were more likely to be exposed; older patients (> 70 years) were less likely to be screened when exposed. The next stage involved identification of solutions to the problem of inappropriate patient exposure through the medium of a multi-disciplinary focus group. The focus group recommended raising staff awareness and documentation of situations that may compromise maintenance of dignity. The final stage of the study involved an audit of these recommendations. The main audit findings were more adequate clothing of patients plus a high level of staff awareness of patients' dignity needs.

The quinary pattern of blast injury.

PubMed

Kluger, Yoram; Nimrod, Adi; Biderman, Philippe; Mayo, Ami; Sorkin, Patric

2007-01-01

Bombing is the primary weapon of global terrorism, and it results in a complicated, multidimensional injury pattern. It induces bodily injuries through the well-documented primary, secondary, tertiary, and quaternary mechanisms of blast. Their effects dictate special medical concern and timely implementation of diagnostic and management strategies. Our objective is to report on clinical observations of patients admitted to the Tel Aviv Medical Center following a terrorist bombing. The explosion injured 27 patients, and three died. Four survivors who had been in close proximity to the explosion, as indicated by their eardrum perforation and additional blast injuries, were exposed to the blast wave. They exhibited a unique and immediate hyperinflammatory state, two upon admission to the intensive care unit and two during surgery. This hyperinflammatory state manifested as hyperpyrexia, sweating, low central venous pressure, and positive fluid balance. This state did not correlate with the complexity of injuries sustained by any of the 67 patients admitted to the intensive care unit after previous bombings. The patients' hyperinflammatory behavior, unrelated to their injury complexity and severity of trauma, indicates a new injury pattern in explosions, termed the "quinary blast injury pattern." Unconventional materials used in the manufacture of the explosive can partly explain the observed early hyperinflammatory state. Medical personnel caring for blast victims should be aware of this new type of bombing injury.

Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU).

PubMed

Nelson, Judith E; Bassett, Rick; Boss, Renee D; Brasel, Karen J; Campbell, Margaret L; Cortez, Therese B; Curtis, J Randall; Lustbader, Dana R; Mulkerin, Colleen; Puntillo, Kathleen A; Ray, Daniel E; Weissman, David E

2010-09-01

To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings. We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms "intensive care," "critical care," or "ICU" and "palliative care"; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report. We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families. There are two main models for intensive care unit-palliative care integration: 1) the "consultative model," which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the "integrative model," which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.

[Factors of successful integrated care settings for total knee and hip arthroplasty: findings of a qualitative process analysis].

PubMed

Bartel, S; Bethge, M; Streibelt, M; Thren, K; Lassahn, C

2010-06-01

In Germany, introduction of the law on Integrated Health Care (IC) (section sign 140a-d SGB V) opened up the possibility of cross-sectoral health care settings and new forms of remuneration, and improved the conditions for a closer cooperation between health care providers. However, cross-institutional and interdisciplinary work contexts demand new organizational structures in order to assure the coordination of different competences, resources and interests. This study aims at identifying factors of successful integrated care settings for total hip and knee arthroplasty. Using the example of an integrated care setting between an orthopaedic hospital and a rehabilitation clinic it will be examined which factors lead to successful implementation of the services and measures designed. A qualitative research design was developed comprising different methods of data assessment (participant observation, guided expert interviews, document analyses) enabling a comprehensive exploration. Overall, data were derived from six consultations with patients, two integrated care information sessions and various documents (17 patient files, information material, patient lists, etc.). First of all, the different phases of development and implementation of integrated care settings were described. In this context, clearly defined aims, structures and appropriate measures seem to be crucial for an ideal long-term cooperation. Furthermore, the staff perspective on the effects of the IC programme on their daily routines proved an essential basis for process reconstruction. The staff members pointed out four main aspects regarding IC settings, i. e., improved image, increased knowledge, intensity of relationship, and less and more work effort. Against this background, factors of successful IC settings could be generated such as the need for central coordination, a regular staff information systems as well as accompanying process monitoring. Several key factors of successful integrated care settings in arthroplasty could be generated which provide important clues for shaping future interdisciplinary and cross-sectoral cooperation settings in health care services in general. Georg Thieme Verlag KG Stuttgart New York.

Thank you letters from patients in an intensive care unit: From the expression of gratitude to an applied ethic of care.

PubMed

Herbland, Alexandre; Goldberg, Michel; Garric, Nathalie; Lesieur, Olivier

2017-12-01

Patients' perception of an intensive care unit stay can lead to a better understanding of the expectations and needs of patients hospitalised in intensive care so that care for critically ill patients can be adapted and improved. Thank you letters are sources of original information which come directly and spontaneously from patients. The objective of this study was to analyse the thank you letters from patients who required intensive care treatment and to identify messages that could be intended for the intensive care unit team. We conducted a qualitative study according to a thematic analysis. The body of research consisted of 17 letters from patients hospitalised in intensive care unit. The study took place in the medical-surgical intensive care unit of a French general hospital. The intensive care unit is made up of 16 resuscitation beds and four continuous monitoring beds. Two main themes emerged: (i) expression of gratitude through a description of the caregivers' behaviour (humanity and professionalism) and recognition for surviving (ii) the narrative of the intensive care unit experience. Thank you letters give a rich insight into how the patients perceived their stay in intensive care unit. Letters from patients give direct feedback on the quality of care provided, contribute to give meaning to work and raise the question of what the core values of care should be for all concerned in the healthcare providers-patients relationship. Copyright © 2017 Elsevier Ltd. All rights reserved.

Use of Electronic Documentation for Quality Improvement in Hospice

PubMed Central

Cagle, John G.; Rokoske, Franziska S.; Durham, Danielle; Schenck, Anna P.; Spence, Carol; Hanson, Laura C.

2015-01-01

Little evidence exists on the use of electronic documentation in hospice and its relationship to quality improvement practices. The purposes of this study were to: (1) estimate the prevalence of electronic documentation use in hospice; (2) identify organizational characteristics associated with use of electronic documentation; and (3) determine whether quality measurement practices differed based on documentation format (electronic vs. nonelectronic). Surveys concerning the use of electronic documentation for quality improvement practices and the monitoring of quality-related care and outcomes were collected from 653 hospices. Users of electronic documentation were able to monitor a wider range of quality-related data than users of nonelectronic documentation. Quality components such as advanced care planning, cultural needs, experience during care of the actively dying, and the number/types of care being delivered were more likely to be documented by users of electronic documentation. Use of electronic documentation may help hospices to monitor quality and compliance. PMID:22267819

The impact of a simplified documentation method for the Edmonton classification system for cancer pain (ECS-CP) on clinician utilization.

PubMed

Tanco, Kimberson; Arthur, Joseph; Haider, Ali; Stephen, Saneese; Yennu, Sriram; Liu, Diane; Bruera, Eduardo

2017-02-01

The use of standardized pain classification systems such as the ECS-CP can assist in the assessment and management of cancer pain. However, its completion has been limited due to its perceived complexity of decoding each feature. The objectives of this study were to determine the rate of clinician documentation and completion of the ECS-CP features after revision and simplification of the response for each feature. Electronic records of consecutive patient visits at the outpatient supportive care center seen by 12 palliative medicine specialists were collected at 6 months before (pre-interventional period), 6 and 24 months after (post-interventional period) the implementation of the simplified ECS-CP tool. Rate of ECS-CP documentation, completion, and analysis of patient and physician predictors were completed. One thousand and twelve patients' documentation was analyzed: 343 patients, before; 341 patients, 6 months after, and 328 patients, 24 months after the intervention. ≥2/5 items were completed before the intervention, 6 months after the intervention and 24 months after intervention in 0/343 (0 %), 136/341 (40 %), and 238/328 (73 %), respectively (p < 0.001). 5/5 items were completed before the intervention, 6 months after the intervention and 24 months after intervention in 0/343 (0 %), 131/341 (38 %), and 222/328 (68 %), respectively, (p < 0.001). There were no patient or physician predictors found significant for successful documentation of ECS-CP. Our findings suggest that significant simplification and intensive education is necessary for successful adoption of a scoring system. More research is needed in order to identify how to adopt tools for daily clinical practice in palliative care.

Management of venous thromboembolism.

PubMed

Parakh, R; Kakkar, V V; Kakkar, A K

2007-01-01

Venous Thromboembolism is an important healthcare problem the world over, resulting in significant morbidity, mortality and resource expenditure. The rationale for use of thromboprophylaxis is based on solid principles and scientific evidence. Indian perspective on this topic is lacking due to the non-availability of published Indian data. This document reviews the available International and Indian data and discusses the relevance of recommendations for prevention and management of Venous Thromboembolism (VTE) in the Indian context. Meetings of various specialists from different Indian hospitals in the field of Gastrointestinal Surgery, General and Vascular Surgery, Hematology, Intensive Care, Obstetrics and Gynecology, Oncology and Orthopedics were held in the months of August 2005 to January 2006. The guidelines published by American College of Chest Physicians (ACCP), the International Union of Angiology (IUA), and the Royal College of Obstetricians and Gynecologists (RCOG), were discussed during these meetings. The relevance of these guidelines and the practical implications of following these in a developing country like India were also discussed. Any published data from India was collected from data base searches and the results, along with personal experiences of the participating specialists were discussed. The experiences and impressions of the experts during these meetings have been included in this document. Data from recent sources (International Union of Angiology and the National Comprehensive Cancer Network (NCCN) Practice guidelines in Oncology on Venous thromboembolic disease) was subsequently also included in this document. The suggestions formulated in this document are practical, and would intend to serve as a useful practical reference. A number of unanswered questions remain in the field of thromboprophylaxis, and carefully designed research protocols may help answer some of these. Implementation of the suggestions outlined in the document remains to be studied in the Indian context.

Hospice palliative care article publications: An analysis of the Web of Science database from 1993 to 2013.

PubMed

Chang, Hsiao-Ting; Lin, Ming-Hwai; Chen, Chun-Ku; Hwang, Shinn-Jang; Hwang, I-Hsuan; Chen, Yu-Chun

2016-01-01

Academic publications are important for developing a medical specialty or discipline and improvements of quality of care. As hospice palliative care medicine is a rapidly growing medical specialty in Taiwan, this study aimed to analyze the hospice palliative care-related publications from 1993 through 2013 both worldwide and in Taiwan, by using the Web of Science database. Academic articles published with topics including "hospice", "palliative care", "end of life care", and "terminal care" were retrieved and analyzed from the Web of Science database, which includes documents published in Science Citation Index-Expanded and Social Science Citation Indexed journals from 1993 to 2013. Compound annual growth rates (CAGRs) were calculated to evaluate the trends of publications. There were a total of 27,788 documents published worldwide during the years 1993 to 2013. The top five most prolific countries/areas with published documents were the United States (11,419 documents, 41.09%), England (3620 documents, 13.03%), Canada (2428 documents, 8.74%), Germany (1598 documents, 5.75%), and Australia (1580 documents, 5.69%). Three hundred and ten documents (1.12%) were published from Taiwan, which ranks second among Asian countries (after Japan, with 594 documents, 2.14%) and 16(th) in the world. During this 21-year period, the number of hospice palliative care-related article publications increased rapidly. The worldwide CAGR for hospice palliative care publications during 1993 through 2013 was 12.9%. As for Taiwan, the CAGR for publications during 1999 through 2013 was 19.4%. The majority of these documents were submitted from universities or hospitals affiliated to universities. The number of hospice palliative care-related publications increased rapidly from 1993 to 2013 in the world and in Taiwan; however, the number of publications from Taiwan is still far below those published in several other countries. Further research is needed to identify and try to reduce the barriers to hospice palliative care research and publication in Taiwan. Copyright © 2015. Published by Elsevier Taiwan LLC.

The unexpected but understandable dynamics of mating, paternity and paternal care in the ocellated wrasse

PubMed Central

Alonzo, Suzanne H.; Heckman, Kellie L.

2010-01-01

Although theory generally predicts that males should reduce paternal care in response to cues that predict increased sperm competition and decreased paternity, empirical patterns are equivocal. Some studies have found the predicted decrease in male care with increased sperm competition, while even more studies report no effect of paternity or sperm competition on male care. Here, we report the first example, to our knowledge, of paternal care increasing with the risk and intensity of sperm competition, in the ocellated wrasse (Symphodus ocellatus). Theory also predicts that if paternal care varies and is important to female fitness, female choice among males and male indicators traits of expected paternal care should evolve. Despite a non-random distribution of mating success among nests, we found no evidence for female choice among parental males. Finally, we document the highest published levels of extra-pair paternity for a species with exclusive and obligate male care: genetic paternity analyses revealed cuckoldry at 100 per cent of nests and 28 per cent of all offspring were not sired by the male caring for them. While not predicted by any existing theory, these unexpected reproductive patterns become understandable if we consider how male and female mating and parental care interact simultaneously in this and probably many other species. PMID:19812085

Making a measurable difference in advanced Huntington disease care.

PubMed

Moskowitz, Carol Brown; Rao, Ashwini K

2017-01-01

Neurologists' role in the care of people with advanced Huntington disease (HD) (total functional capacity <7), often limited by a lack of clinical research to support good practice, includes the following: (1) provide comprehensive health records to an interdisciplinary care staff before admission to a more intense care setting (home health services, day program, assisted living, group home, long-term skilled nursing facility, palliative care); (2) consult with and refer to rehabilitation (occupational therapy, physical therapy, speech and language pathology), behavioral and psychiatric professionals for problem-solving strategies, which must be reviewed with direct care staff before implementation; (3) encourage and support qualitative and quantitative interdisciplinary research studies, and randomized controlled studies of nonpharmacologic interventions; and (4) assist in the development of meaningful measures to further document what works to provide a good quality of life for the patient and family and a comfortable thoughtful approach to a good death. Collaborative models of care depend on: (1) clear communication; (2) ongoing education and support programs; with (3) pharmacologic and rehabilitation interventions, always in the context of respect for the person with HD, a preservation of the individuals' dignity, autonomy, and individual preferences. Copyright © 2017 Elsevier B.V. All rights reserved.

Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data

PubMed Central

Griesdale, Donald E.G.; de Souza, Russell J.; van Dam, Rob M.; Heyland, Daren K.; Cook, Deborah J.; Malhotra, Atul; Dhaliwal, Rupinder; Henderson, William R.; Chittock, Dean R.; Finfer, Simon; Talmor, Daniel

2009-01-01

Background Hyperglycemia is associated with increased mortality in critically ill patients. Randomized trials of intensive insulin therapy have reported inconsistent effects on mortality and increased rates of severe hypoglycemia. We conducted a meta-analysis to update the totality of evidence regarding the influence of intensive insulin therapy compared with conventional insulin therapy on mortality and severe hypoglycemia in the intensive care unit (ICU). Methods We conducted searches of electronic databases, abstracts from scientific conferences and bibliographies of relevant articles. We included published randomized controlled trials conducted in the ICU that directly compared intensive insulin therapy with conventional glucose management and that documented mortality. We included in our meta-analysis the data from the recent NICE-SUGAR (Normoglycemia in Intensive Care Evaluation — Survival Using Glucose Algorithm Regulation) study. Results We included 26 trials involving a total of 13 567 patients in our meta-analysis. Among the 26 trials that reported mortality, the pooled relative risk (RR) of death with intensive insulin therapy compared with conventional therapy was 0.93 (95% confidence interval [CI] 0.83–1.04). Among the 14 trials that reported hypoglycemia, the pooled RR with intensive insulin therapy was 6.0 (95% CI 4.5–8.0). The ICU setting was a contributing factor, with patients in surgical ICUs appearing to benefit from intensive insulin therapy (RR 0.63, 95% CI 0.44–0.91); patients in the other ICU settings did not (medical ICU: RR 1.0, 95% CI 0.78–1.28; mixed ICU: RR 0.99, 95% CI 0.86–1.12). The different targets of intensive insulin therapy (glucose level ≤ 6.1 mmol/L v. ≤ 8.3 mmol/L) did not influence either mortality or risk of hypoglycemia. Interpretation Intensive insulin therapy significantly increased the risk of hypoglycemia and conferred no overall mortality benefit among critically ill patients. However, this therapy may be beneficial to patients admitted to a surgical ICU. PMID:19318387

Care needs of older patients in the intensive care units.

PubMed

Chang, Ching-Wen; Chen, Yuh-Min; Su, Ching-Ching

2012-03-01

To explore the care needs of older patients in the intensive care units. Background.  As the numbers of older patients admitted to the intensive care units are growing, care quality of critically ill older patients has become an important issue. However, there are few studies directly investigating perceived care needs of hospitalised older patients and the studies on care needs of older patients in the intensive care units are even fewer. The identification of care needs from older patients' perspective will help develop qualified nursing practice. A qualitative exploratory design. Purposive sampling was performed to recruit 35 older patients from three hospitals in Taiwan. The interview transcripts were analysed by qualitative content analysis. The results revealed that care needs of older patients in the intensive care units are multidimensional, including physical, informational and psychosocial dimensions. Older patients' needs of the physical dimension included relieving pain and discomfort, starting oral intake as soon as possible and having continuous sleep. Informational needs included adequate explanations about their disease progression and prognosis and information on recovery-promoting activity. Psychosocial needs included caring behaviour of intensive care units staff, flexible visiting hours, increase in control ability and maintenance of good communication with intensive care units staff. The findings can assist nurses in understanding the interventions necessary to meet care needs of critically ill older patients. The critically ill older adults need more than medical-technical care. They need more holistic care. The psychosocial and informational needs must be considered commensurate with the presenting physical needs. Nurses have an important role in meeting intensive care units older patients' care needs. Intensive care units nurses should conduct comprehensive assessment regarding older patients' needs at the beginning and at various points in their intensive care units stay and match these needs with appropriate nursing interventions. © 2011 Blackwell Publishing Ltd.

Assessing the Impact of Telemedicine on Nursing Care in Intensive Care Units.

PubMed

Kleinpell, Ruth; Barden, Connie; Rincon, Teresa; McCarthy, Mary; Zapatochny Rufo, Rebecca J

2016-01-01

Information on the impact of tele-intensive care on nursing and priority areas of nursing care is limited. To conduct a national benchmarking survey of nurses working in intensive care telemedicine facilities in the United States. In a 2-phased study, an online survey was used to assess nurses' perceptions of intensive care telemedicine, and a modified 2-round Delphi study was used to identify priority areas of nursing. In phase 1, most of the 1213 respondents agreed to strongly agreed that using tele-intensive care enables them to accomplish tasks more quickly (63%), improves collaboration (65.9%), improves job performance (63.6%) and communication (60.4%), is useful in nursing assessments (60%), and improves care by providing more time for patient care (45.6%). Benefits of tele-intensive care included ability to detect trends in vital signs, detect unstable physiological status, provide medical management, and enhance patient safety. Barriers included technical problems (audio and video), interruptions in care, perceptions of telemedicine as an interference, and attitudes of staff. In phase 2, 60 nurses ranked 15 priority areas of care, including critical thinking skills, intensive care experience, skillful communication, mutual respect, and management of emergency patient care. The findings can be used to further inform the development of competencies for tele-intensive care nursing, match the tele-intensive care nursing practice guidelines of the American Association of Critical-Care Nurses, and highlight concepts related to the association's standards for establishing and sustaining healthy work environments. ©2016 American Association of Critical-Care Nurses.

Impact of a novel online learning module on specialist palliative care nurses' pain assessment competencies and patients' reports of pain: Results from a quasi-experimental pilot study.

PubMed

Phillips, Jane L; Heneka, Nicole; Hickman, Louise; Lam, Lawrence; Shaw, Tim

2014-06-01

Pain is a complex multidimensional phenomenon moderated by consumer, provider and health system factors. Effective pain management cuts across professional boundaries, with failure to screen and assess contributing to the burden of unrelieved pain. To test the impact of an online pain assessment learning module on specialist palliative care nurses' pain assessment competencies, and to determine whether this education impacted positively on palliative care patients' reported pain ratings. A quasi-experimental pain assessment education pilot study utilising 'Qstream © ', an online methodology to deliver 11 case-based pain assessment learning scenarios, developed by an interdisciplinary expert panel and delivered to participants' work emails over a 28-day period in mid-2012. The 'Self-Perceived Pain Assessment Competencies' survey and chart audit data, including patient-reported pain intensity ratings, were collected pre-intervention (T1) and post-intervention (T2) and analysed using inferential statistics to determine key outcomes. Nurses working at two Australian inpatient specialist palliative care services in 2012. The results reported conform to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Guidelines. Participants who completed the education intervention ( n = 34) increased their pain assessment knowledge, assessment tool knowledge and confidence to undertake a pain assessment ( p < 0.001). Participants were more likely to document pain intensity scores in patients' medical records than non-participants (95% confidence interval = 7.3%-22.7%, p = 0.021). There was also a significant reduction in the mean patient-reported pain ratings between the admission and audit date at post-test of 1.5 (95% confidence interval = 0.7-2.3) units in pain score. This pilot confers confidence of the education interventions capacity to improve specialist palliative care nurses' pain assessment practices and to reduce patient-rated pain intensity scores.

Survey of current status of intensive care teaching in English-speaking medical schools.

PubMed

Shen, Judith; Joynt, Gavin M; Critchley, Lester A H; Tan, Ian K S; Lee, Anna

2003-01-01

To identify a consensus of opinion regarding the content of an intensive care core syllabus for undergraduate medical students and factors that may limit its teaching. Cross-sectional postal survey containing 35 items ranging from department structure to curriculum content and factors that limit the teaching of intensive care. English-speaking medical schools (n = 210) listed in the 1986 World Health Organization Directory. Of 122 (58%) returned questionnaires, a 45% return was achieved from the United States and 86% from non-U.S. countries. Most respondents (84%) considered teaching undergraduate intensive care to be essential; however, teaching intensive care was compulsory in only 31% of schools. Many schools (43%) reported recent changes to their intensive care curriculum. Most respondents (60%) thought that intensive care specialists should teach and that each student required a median (interquartile range) of 20 (10-80) hrs of teacher contact time. Resuscitation skills were taught in 98% of schools. In comparison, 63% of schools had no intensive care syllabus. More than 90% of respondents thought that the intensive care syllabus should include the following: cardiopulmonary resuscitation, assessment and management of the acutely ill patient; management of respiratory, circulatory, and multiple organ system failure (including systemic inflammatory response syndrome and sepsis); management of the unconscious patient; early postoperative care; and communication skills and ethics as they relate to end-of-life issues. Factors that limited intensive care teaching were lack of staff, funding, and time dedicated to teaching and excessive clinical workload. Student performance in intensive care was assessed by 66% of schools, but only 28% used a written or oral examination. By surveying a wide range of medical schools internationally, we have been able to define an undergraduate intensive care syllabus that could be delivered in 20 hrs or 1 wk of dedicated teaching time. Factors that impede the provision of undergraduate intensive care teaching are a lack of staff, funding, and dedicated teaching time.

Psychological recovery after intensive care: Outcomes of a long-term quasi-experimental study of structured nurse-led follow-up.

PubMed

Jónasdóttir, Rannveig J; Jónsdóttir, Helga; Gudmundsdottir, Berglind; Sigurdsson, Gisli H

2018-02-01

To compare psychological recovery of patients receiving structured nurse-led follow-up and patients receiving usual care after intensive care discharge. Quasi-experimental study. Single centre, university hospital, mixed intensive care patient population. Symptoms of post-traumatic stress disorder, anxiety and depression measured three and four times over 12 months after intensive care discharge. Disturbing memories of the intensive care stay and psychological reactions (that one's life was in danger, threat to physical integrity, intense fear, helplessness, horror) three months after intensive care. A mixed effect model tested differences between the groups over time and regression model predicted post-traumatic stress at three months. The experimental group had significantly more symptoms of post-traumatic stress and anxiety than the control group over the 12 months. Patients from both groups had severe symptoms of post-traumatic stress. Patients with post-traumatic stress at three months had disturbing memories and psychological reactions. The structured nurse-led follow-up did not improve patients' measured outcomes of psychological recovery after intensive care. Patients with severe symptoms of post-traumatic stress are of concern. Emphasis needs to be placed on disturbing memories of the intensive care stay and psychological reactions when constructing intensive care nurse-led follow-up. Copyright © 2017 Elsevier Ltd. All rights reserved.

Structured nurse-led follow-up for patients after discharge from the intensive care unit: Prospective quasi-experimental study.

PubMed

Jónasdóttir, Rannveig J; Jones, Christina; Sigurdsson, Gisli H; Jónsdóttir, Helga

2018-03-01

The aim of this study was to describe a structured 3-month nurse-led follow-up of patients after discharge from intensive care and measure its effects on health status. Patients requiring intensive care stay frequently have lengthy and incomplete recovery suggesting need for additional support. The effects of intensive care nurse-led follow-up have not been sufficiently elucidated. A prospective, quasi-experimental study of patients who received structured nurse-led follow-up from intensive care nurses after discharge from intensive care until 3 months afterwards. The control group received usual care. Of 574 patients assessed for eligibility, from November 2012 - May 2015, 168 were assigned to the experimental group (N = 73) and the control group (N = 75). Primary outcome was health status, measured with eight scales of Short Form-36v2, before the intensive care admission and at four time points until 12 months after intensive care. A mixed effect model tested differences between the groups over time. Criteria for Reporting Development and Evaluation of Complex Interventions 2 guideline, guided the reporting of the intervention. The structured nurse-led follow-up did not improve patients' health status compared with usual care (mixed effect model, p = .078-.937). The structured nurse-led follow-up did not reveal an effect on the intensive care patients studied. Further examination of intensive care nurse-led follow-up is needed, taking into account the heterogeneity of the patient population, variations in length of ward stay, patients' health care needs during the first week at home after discharge from general ward and health status before intensive care admission. © 2017 John Wiley & Sons Ltd.

Point-of-care blood glucose measurement errors overestimate hypoglycaemia rates in critically ill patients.

PubMed

Nya-Ngatchou, Jean-Jacques; Corl, Dawn; Onstad, Susan; Yin, Tom; Tylee, Tracy; Suhr, Louise; Thompson, Rachel E; Wisse, Brent E

2015-02-01

Hypoglycaemia is associated with morbidity and mortality in critically ill patients, and many hospitals have programmes to minimize hypoglycaemia rates. Recent studies have established the hypoglycaemic patient-day as a key metric and have published benchmark inpatient hypoglycaemia rates on the basis of point-of-care blood glucose data even though these values are prone to measurement errors. A retrospective, cohort study including all patients admitted to Harborview Medical Center Intensive Care Units (ICUs) during 2010 and 2011 was conducted to evaluate a quality improvement programme to reduce inappropriate documentation of point-of-care blood glucose measurement errors. Laboratory Medicine point-of-care blood glucose data and patient charts were reviewed to evaluate all episodes of hypoglycaemia. A quality improvement intervention decreased measurement errors from 31% of hypoglycaemic (<70 mg/dL) patient-days in 2010 to 14% in 2011 (p < 0.001) and decreased the observed hypoglycaemia rate from 4.3% of ICU patient-days to 3.4% (p < 0.001). Hypoglycaemic events were frequently recurrent or prolonged (~40%), and these events are not identified by the hypoglycaemic patient-day metric, which also may be confounded by a large number of very low risk or minimally monitored patient-days. Documentation of point-of-care blood glucose measurement errors likely overestimates ICU hypoglycaemia rates and can be reduced by a quality improvement effort. The currently used hypoglycaemic patient-day metric does not evaluate recurrent or prolonged events that may be more likely to cause patient harm. The monitored patient-day as currently defined may not be the optimal denominator to determine inpatient hypoglycaemic risk. Copyright © 2014 John Wiley & Sons, Ltd.

Harnessing electronic healthcare data for wound care research: Standards for reporting observational registry data obtained directly from electronic health records.

PubMed

Fife, Caroline E; Eckert, Kristen A

2017-04-01

The United States Food and Drug Administration will consider the expansion of coverage indications for some drugs and devices based on real-world data. Real-world data accrual in patient registries has historically been via manual data entry from the medical chart at a time distant from patient care, which is fraught with systematic error. The efficient automated transmission of data directly from electronic health records is replacing this labor-intensive paradigm. However, real-world data collection is unfamiliar. The potential sources of bias arising from the source of data and data accrual, documentation, and aggregation have not been well defined. Furthermore, the technological aspects of data acquisition and transmission are less transparent. We explore opportunities for harnessing direct-from-electronic health record registry reporting and propose the ABCs of Registries (Analysis of Bias Criteria of Registries), which are an evaluation framework for publications to minimize potential bias of real-world data obtained directly from an electronic health record method. These standards are based on a point-of-care data documentation process using a common definitional framework and data dictionaries. By way of example, we describe a wound registry obtained directly from electronic health records. This qualified clinical data registry minimizes bias by ensuring complete and accurate point-of-care data capture, standardizes usual care linked to quality reporting, and prevents post-hoc vetting of outcomes. The resulting data are of high quality and integrity and can be used for comparative effectiveness research in wound care. In this way, the effort needed to succeed with the Quality Payment Program is leveraged to obtain the real-world data needed for comparative effectiveness research. © 2017 by the Wound Healing Society.

Interhospital transfer handoff practices among US tertiary care centers: A descriptive survey.

PubMed

Herrigel, Dana J; Carroll, Madeline; Fanning, Christine; Steinberg, Michael B; Parikh, Amay; Usher, Michael

2016-06-01

Interhospital transfer is an understudied area within transitions of care. The process by which hospitals accept and transfer patients is not well described. National trends and best practices are unclear. To describe the demographics of large transfer centers, to identify common handoff practices, and to describe challenges and notable innovations involving the interhospital transfer handoff process. A convenience sample of 32 tertiary care centers in the United States was studied. Respondents were typically transfer center directors surveyed by phone. Data regarding transfer center demographics, handoff communication practices, electronic infrastructure, and data sharing were obtained. The median number of patients transferred each month per receiving institution was 700 (range, 250-2500); on average, 28% of these patients were transferred to an intensive care unit. Transfer protocols and practices varied by institution. Transfer center coordinators typically had a medical background (78%), and critical care-trained registered nurse was the most prevalent (38%). Common practices included: mandatory recorded 3-way physician-to-physician conversation (84%) and mandatory clinical status updates prior to patient arrival (81%). However, the timeline of clinical status updates was variable. Less frequent transfer practices included: electronic medical record (EMR) cross-talk availability and utilization (23%), real-time transfer center documentation accessibility in the EMR (32%), and referring center clinical documentation available prior to transport (29%). A number of innovative strategies to address challenges involving interhospital handoffs are reported. Interhospital transfer practices vary widely amongst tertiary care centers. Practices that lead to improved patient handoffs and reduced medical errors need additional prospective evaluation. Journal of Hospital Medicine 2016;11:413-417. © 2016 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.

SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis.

PubMed

Maraví Poma, E; Zubia Olascoaga, F; Petrov, M S; Navarro Soto, S; Laplaza Santos, C; Morales Alava, F; Darnell Martin, A; Gorraiz López, B; Bolado Concejo, F; Casi Villarroya, M; Aizcorbe Garralda, M; Albeniz Arbizu, E; Sánchez-Izquierdo Riera, J A; Tirapu León, J P; Bordejé Laguna, L; López Camps, V; Marcos Neira, P; Regidor Sanz, E; Jiménez Mendioroz, F

2013-04-01

Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU. Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations. Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management. Copyright © 2013 Elsevier España, S.L. and SEMICYUC. All rights reserved.

The experience of intensive care nurses caring for patients with delirium: A phenomenological study.

PubMed

LeBlanc, Allana; Bourbonnais, Frances Fothergill; Harrison, Denise; Tousignant, Kelly

2018-02-01

The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) To examine intensive care nurses' experiences of caring for adult patients with delirium; 2) To identify factors that facilitate or hinder intensive care nurses caring for these patients. This study utilised an interpretive phenomenological approach as described by van Manen. Individual conversational interviews were conducted with eight intensive care nurses working in a tertiary level, university-affiliated hospital in Canada. The essence of the experience of nurses caring for patients with delirium in intensive care was revealed to be finding a way to help them come through it. Six main themes emerged: It's Exhausting; Making a Picture of the Patient's Mental Status; Keeping Patients Safe: It's aReally Big Job; Everyone Is Unique; Riding It Out With Families and Taking Every Experience With You. The findings contribute to an understanding of how intensive care nurses help patients and their families through this complex and distressing experience. Copyright © 2017 Elsevier Ltd. All rights reserved.

Personal information documents for people with dementia: Healthcare staff 's perceptions and experiences.

PubMed

Baillie, Lesley; Thomas, Nicola

2018-01-01

Person-centred care is internationally recognised as best practice for the care of people with dementia. Personal information documents for people with dementia are proposed as a way to support person-centred care in healthcare settings. However, there is little research about how they are used in practice. The aim of this study was to analyse healthcare staff 's perceptions and experiences of using personal information documents, mainly Alzheimer's Society's 'This is me', for people with dementia in healthcare settings. The method comprised a secondary thematic analysis of data from a qualitative study, of how a dementia awareness initiative affected care for people with dementia in one healthcare organisation. The data were collected through 12 focus groups (n = 58 participants) and 1 individual interview, conducted with a range of healthcare staff, both clinical and non-clinical. There are four themes presented: understanding the rationale for personal information documents; completing personal information documents; location for personal information documents and transfer between settings; impact of personal information documents in practice. The findings illuminated how healthcare staff use personal information documents in practice in ways that support person-centred care. Practical issues about the use of personal information documents were revealed and these may affect the optimal use of the documents in practice. The study indicated the need to complete personal information documents at an early stage following diagnosis of dementia, and the importance of embedding their use across care settings, to support communication and integrated care.

A description of medication errors reported by pharmacists in a neonatal intensive care unit.

PubMed

Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila

2017-02-01

Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.

Using Arden Syntax for the Generation of Intelligent Intensive Care Discharge Letters.

PubMed

Kraus, Stefan; Castellanos, Ixchel; Albermann, Matthias; Schuettler, Christina; Prokosch, Hans-Ulrich; Staudigel, Martin; Toddenroth, Dennis

2016-01-01

Discharge letters are an important means of communication between physicians and nurses from intensive care units and their colleagues from normal wards. The patient data management system (PDMS) used at our local intensive care units provides an export tool to create discharge letters by inserting data items from electronic medical records into predefined templates. Local intensivists criticized the limitations of this tool regarding the identification and the further processing of clinically relevant data items for a flexible creation of discharge letters. As our PDMS supports Arden Syntax, and the demanded functionalities are well within the scope of this standard, we set out to investigate the suitability of Arden Syntax for the generation of discharge letters. To provide an easy-to-understand facility for integrating data items into document templates, we created an Arden Syntax interface function which replaces the names of previously defined variables with their content in a way that permits arbitrary custom formatting by clinical users. Our approach facilitates the creation of flexible text sections by conditional statements, as well as the integration of arbitrary HTML code and dynamically generated graphs. The resulting prototype enables clinical users to apply the full set of Arden Syntax language constructs to identify and process relevant data items in a way that far exceeds the capabilities of the PDMS export tool. The generation of discharge letters is an uncommon area of application for Arden Syntax, considerably differing from its original purpose. However, we found our prototype well suited for this task and plan to evaluate it in clinical production after the next major release change of our PDMS.

Comparison of terminally ill cancer- vs. non-cancer patients in specialized palliative home care in Germany - a single service analysis.

PubMed

Stiel, Stephanie; Heckel, Maria; Seifert, Andreas; Frauendorf, Tobias; Hanke, Roland Martin; Ostgathe, Christoph

2015-07-25

Palliative care (PC) is no longer offered with preference to cancer patients (CA), but also to patients with non-malignant, progressive diseases. Taking current death statistics into account, PC in Europe will face a growing number of patients dying from non-cancer diseases (NCA). More insights into specialized palliative home care (SPHC) in NCAs are needed. Retrospective analysis and group comparisons between CAs and NCAs of anonymous data of all patients cared for between December 2009 and June 2012 by one SPHC team in Germany. Patient-, disease- and care-related data are documented in clinical routine by specialized PC physicians and nurses in the Information System Palliative Care 3.0 ® (ISPC®). Overall, 502 patients were cared for by the SPHC team; from 387 patients comprehensive data sets were documented. These 387 data sets (CA: N = 300, 77.5 % and NCA: N = 87, 22.5 %) are used for further analysis here. NCAs were significantly older (81 vs. 73 years; p < .001), than CAs and most often suffered from diseases of the nervous system (40 %). They needed significantly more assistance with defecation (87 vs. 74 %; p < .001) and urination (47 vs. 29 %; p < .001) and were more often affected from impaired vigilance (30 vs. 11 %; p < .001) than CAs. A by trend higher proportion of NCAs died within one day after admission to palliative home care (12 vs. 5 %; p < .05) and a smaller proportion was re-admitted to hospital during home care (6 vs. 20 %; p < .001). NCAs died predominantly in nursing homes (50 vs. 20 %; p < .001). Although the proportion of NCAs was relatively high in this study, the access to PC services seems to takes place late in the disease trajectory, as demonstrated by the lower survival rate for NCAs. Nevertheless, the results show, that NCAs PC needs are as complex and intense as in CAs.

E-documentation as a process management tool for nursing care in hospitals.

PubMed

Rajkovic, Uros; Sustersic, Olga; Rajkovic, Vladislav

2009-01-01

Appropriate documentation plays a key role in process management in nursing care. It includes holistic data management based on patient's data along the clinical path with regard to nursing care. We developed an e-documentation model that follows the process method of work in nursing care. It assesses the patient's status on the basis of Henderson's theoretical model of 14 basic living activities and is aligned with internationally recognized nursing classifications. E-documentation development requires reengineering of existing documentation and facilitates process reengineering. A prototype solution of an e-nursing documentation, already being in testing process at University medical centres in Ljubljana and Maribor, will be described.

Intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care: a descriptive qualitative study.

PubMed

Ballangrud, Randi; Hall-Lord, Marie Louise; Persenius, Mona; Hedelin, Birgitta

2014-08-01

To describe intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care. Failures in team processes are found to be contributory factors to incidents in an intensive care environment. Simulation-based training is recommended as a method to make health-care personnel aware of the importance of team working and to improve their competencies. The study uses a qualitative descriptive design. Individual qualitative interviews were conducted with 18 intensive care nurses from May to December 2009, all of which had attended a simulation-based team training programme. The interviews were analysed by qualitative content analysis. One main category emerged to illuminate the intensive care nurse perception: "training increases awareness of clinical practice and acknowledges the importance of structured work in teams". Three generic categories were found: "realistic training contributes to safe care", "reflection and openness motivates learning" and "finding a common understanding of team performance". Simulation-based team training makes intensive care nurses more prepared to care for severely ill patients. Team training creates a common understanding of how to work in teams with regard to patient safety. Copyright © 2014 Elsevier Ltd. All rights reserved.

[Concept for a department of intensive care].

PubMed

Nierhaus, A; de Heer, G; Kluge, S

2014-10-01

Demographic change and increasing complexity are among the reasons for high-tech critical care playing a major and increasing role in today's hospitals. At the same time, intensive care is one of the most cost-intensive departments in the hospital. To guarantee high-quality care, close cooperation of specialised intensive care staff with specialists of all other medical areas is essential. A network of the intensive care units within the hospital may lead to synergistic effects concerning quality of care, simultaneously optimizing the use of human and technical resources. Notwithstanding any organisational concepts, development and maintenance of the highest possible quality of care should be of overriding importance.

Organizational Factors Associated With Perceived Quality of Patient Care in Closed Intensive Care Units.

PubMed

McIntosh, Nathalie; Oppel, Eva; Mohr, David; Meterko, Mark

2017-09-01

Improving patient care quality in intensive care units is increasingly important as intensive care unit services account for a growing proportion of hospital services. Organizational factors associated with quality of patient care in such units have been identified; however, most were examined in isolation, making it difficult to assess the relative importance of each. Furthermore, though most intensive care units now use a closed model, little research has been done in this specific context. To examine the relative importance of organizational factors associated with patient care quality in closed intensive care units. In a national exploratory, cross-sectional study focused on intensive care units at US Veterans Health Administration acute care hospitals, unit directors were surveyed about nurse and physician staffing, work resources and training, patient care coordination, rounding, and perceptions of patient care quality. Administrative records yielded data on patient volume and facility teaching status. Descriptive statistics, bivariate analyses, and regression modeling were used for data analysis. Sixty-nine completed surveys from directors of closed intensive care units were returned. Regression model results showed that better patient care coordination (β = 0.43; P = .01) and having adequate work resources (β = 0.26; P = .02) were significantly associated with higher levels of patient care quality in such units ( R 2 = 0.22). Augmenting work resources and/or focusing limited hospital resources on improving patient care coordination may be the most productive ways to improve patient care quality in closed intensive care units. ©2017 American Association of Critical-Care Nurses.

Important questions asked by family members of intensive care unit patients.

PubMed

Peigne, Vincent; Chaize, Marine; Falissard, Bruno; Kentish-Barnes, Nancy; Rusinova, Katerina; Megarbane, Bruno; Bele, Nicolas; Cariou, Alain; Fieux, Fabienne; Garrouste-Orgeas, Maite; Georges, Hugues; Jourdain, Merce; Kouatchet, Achille; Lautrette, Alexandre; Legriel, Stephane; Regnier, Bernard; Renault, Anne; Thirion, Marina; Timsit, Jean-Francois; Toledano, Dany; Chevret, Sylvie; Pochard, Frédéric; Schlemmer, Benoît; Azoulay, Elie

2011-06-01

Relatives often lack important information about intensive care unit patients. High-quality information is crucial to help relatives overcome the often considerable situational stress and to acquire the ability to participate in the decision-making process, most notably regarding the appropriate level of care. We aimed to develop a list of questions important for relatives of patients in the intensive care unit. This was a multicenter study. Questions asked by relatives of intensive care unit patients were collected from five different sources (literature, panel of 28 intensive care unit nurses and physicians, 1-wk survey of nurses and 1-wk survey of physicians in 14 intensive care units, and in-depth interviews with 14 families). After a qualitative analysis (framework approach and thematic analysis), questions were rated by 22 relatives and 14 intensive care unit physicians, and the ratings were analyzed using principal component analysis and hierarchical clustering. The five sources produced 2,135 questions. Removal of duplicates and redundancies left 443 questions, which were distributed among nine predefined domains using a framework approach ("diagnosis," "treatment," "prognosis," "comfort," "interaction," "communication," "family," "end of life," and "postintensive care unit management"). Thematic analysis in each domain led to the identification of 46 themes, which were reworded as 46 different questions. Ratings by relatives and physicians showed that 21 of these questions were particularly important for relatives of intensive care unit patients. This study increases knowledge about the informational needs of relatives of intensive care unit patients. This list of questions may prove valuable for both relatives and intensive care unit physicians as a tool for improving communication in the intensive care unit.

Paediatric cardiac intensive care unit: current setting and organization in 2010.

PubMed

Fraisse, Alain; Le Bel, Stéphane; Mas, Bertrand; Macrae, Duncan

2010-10-01

Over recent decades, specialized paediatric cardiac intensive care has emerged as a central component in the management of critically ill, neonatal, paediatric and adult patients with congenital and acquired heart disease. The majority of high-volume centres (dealing with over 300 surgical cases per year) have dedicated paediatric cardiac intensive care units, with the smallest programmes more likely to care for paediatric cardiac patients in mixed paediatric or adult intensive care units. Specialized nursing staff are also a crucial presence at the patient's bedside for quality of care. A paediatric cardiac intensive care programme should have patients (preoperative and postoperative) grouped together geographically, and should provide proximity to the operating theatre, catheterization laboratory and radiology department, as well as to the regular ward. Age-appropriate medical equipment must be provided. An optimal strategy for running a paediatric cardiac intensive care programme should include: multidisciplinary collaboration and involvement with paediatric cardiology, anaesthesia, cardiac surgery and many other subspecialties; a risk-stratification strategy for quantifying perioperative risk; a personalized patient approach; and anticipatory care. Finally, progressive withdrawal from heavy paediatric cardiac intensive care management should be institutionalized. Although the countries of the European Union do not share any common legislation on the structure and organization of paediatric intensive care or paediatric cardiac intensive care, any paediatric cardiac surgery programme in France that is agreed by the French Health Ministry must perform at least '150 major procedures per year in children' and must provide a 'specialized paediatric intensive care unit'. Copyright © 2010 Elsevier Masson SAS. All rights reserved.

From spouse to caregiver and back: a grounded theory study of post-intensive care unit spousal caregiving.

PubMed

Ågård, Anne Sophie; Egerod, Ingrid; Tønnesen, Else; Lomborg, Kirsten

2015-08-01

To explore the challenges and caring activities of spouses of intensive care unit survivors during the first year of patient recovery. Every year, millions of people globally are discharged from an intensive care unit after critical illness to continue treatment, care and rehabilitation in general hospital wards, rehabilitation facilities and at home. Consequently, millions of spouses become informal caregivers. Little is known, however, about the concrete challenges spouses face in post-intensive care unit everyday life. Explorative, qualitative grounded theory study. Participants were spouses of intensive care unit survivors. The study was undertaken in Denmark in 2009-2010. Data consisted of 35 semi-structured dyad interviews at 3 and 12 months post-intensive care unit discharge, two group interviews with patients and two with spouses. 'Shifting their role from spouse to caregiver and back' was identified as the core category of the study. The role shifts progressed in a dynamic process involving four elements: (1) committing to caregiving; (2) acquiring caregiving skills; (3) negotiating level of caregiving and (4) gradually leaving the caregiver role. Post-ICU caregiving comprised five patient dimensions: observing, assisting, coaching, advocating and managing activities. Spouses play a vital and multifaceted role in post-intensive care unit recovery. The findings can inform healthcare professionals in their efforts to prepare intensive care unit patients' families for the time following intensive care unit and hospital discharge. Hospital staff, rehabilitation experts and primary care professionals must acknowledge spouses' important contribution from intensive care unit admission throughout recovery. © 2015 John Wiley & Sons Ltd.

Evaluation of proposed casemix criteria as a basis for costing patients in the adult general intensive care unit.

PubMed

Stevens, V G; Hibbert, C L; Edbrooke, D L

1998-10-01

This study analyses the relationship between the actual patient-related costs of care calculated for 145 patients admitted sequentially to an adult general intensive care unit and a number of factors obtained from a previously described consensus of opinion study. The factors identified in the study were suggested as potential descriptors for the casemix in an intensive care unit that could be used to predict the costs of care. Significant correlations between the costs of care and severity of illness, workload and length of stay were found but these failed to predict the costs of care with sufficient accuracy to be used in isolation to define isoresource groups in the intensive care unit. No associations between intensive care unit mortality, reason for admission and intensive and unit treatments and costs of care were found. Based on these results, it seems that casemix descriptors and isoresource groups for the intensive care unit that would allow costs to be predicted cannot be defined in terms of single factors.

[Cross sectional study of structural quality of German intensive care units. A reevaluation of the DIVI register].

PubMed

Fölsch, C; Kofahl, N; Waydhas, C; Stiletto, R

2013-09-01

Effectiveness of intensive care treatment is essential to cope with increasing costs. The German national register of intensive care established by the German Interdisciplinary Association for Intensive Care Medicine (DIVI) contains basic data on the structure of intensive care units in Germany. A repeat analysis of data of the DIVI register within 8 years provides information for the development of intensive care units under different economic circumstances. The recent data on the structure of intensive care units were obtained in 2008 and compared with the primary multicenter study from 2000. The hospitals selected were a representative sample for the whole of Germany. Data on the status of the hospital, staff and technical facilities, foundation of the hospital and the statistics of mechanically ventilated patients were analyzed. The technical facilities and the number of staff have improved from 2000 to 2008. A smaller availability of diagnostic procedures and staff remain in hospitals for basic treatment outside normal working hours. The average utilization of intensive care unit beds was not altered. The existence of intermediate care units did not significantly change the proportion of patients with artificial ventilation or ventilation times. The number of beds in intensive care units was unchanged as was the average number of beds in units and the number of patients treated. A relevant number of beds of intensive care units shifted towards hospitals with private foundation without changes in the overall numbers. The structure of the hospitals was comparable at both time points. The introduction of intermediate care units did not alter ventilation parameters of patients in 2008 compared with 2000. There is no obvious medical reason for the shift of intensive care beds towards private hospitals. The number of staff and patients varied considerably between the intensive care units. The average number of patients treated per bed was not different between the periods or between hospitals with different structures. Overall availability of medical staff and diagnostic procedures increased during the study period. An increase of availability of fully trained medical staff in intensive care medicine is desirable to increase the quality of treatment.

Care planning for aggression management in a specialist secure mental health service: An audit of user involvement.

PubMed

Hallett, Nutmeg; Huber, Jörg W; Sixsmith, Judith; Dickens, Geoffrey L

2016-12-01

This paper describes an audit of prevention and management of violence and aggression care plans and incident reporting forms which aimed to: (i) report the compliance rate of completion of care plans; (ii) identify the extent to which patients contribute to and agree with their care plan; (iii) describe de-escalation methods documented in care plans; and (iv) ascertain the extent to which the de-escalation methods described in the care plan are recorded as having been attempted in the event of an incident. Care plans and incident report forms were examined for all patients in men's and women's mental health care pathways who were involved in aggressive incidents between May and October 2012. In total, 539 incidents were examined, involving 147 patients and 121 care plans. There was no care plan in place at the time of 151 incidents giving a compliance rate of 72%. It was documented that 40% of patients had contributed to their care plans. Thematic analysis of de-escalation methods documented in the care plans revealed five de-escalation themes: staff interventions, interactions, space/quiet, activities and patient strategies/skills. A sixth category, coercive strategies, was also documented. Evidence of adherence to de-escalation elements of the care plan was documented in 58% of incidents. The reasons for the low compliance rate and very low documentation of patient involvement need further investigation. The inclusion of coercive strategies within de-escalation documentation suggests that some staff fundamentally misunderstand de-escalation. © 2016 Australian College of Mental Health Nurses Inc.

Role of a service corridor in ICU noise control, staff stress, and staff satisfaction: environmental research of an academic medical center.

PubMed

Wang, Zhe; Downs, Betsy; Farell, Ashley; Cook, Kimberly; Hourihan, Peter; McCreery, Shimby

2013-01-01

To investigate the role of a dedicated service corridor in intensive care unit (ICU) noise control and staff stress and satisfaction. Shared corridors immediately adjacent to patient rooms are generally noisy due to a variety of activities, including service deliveries and pickups. The strategy of providing a dedicated service corridor is thought to reduce noise for patient care, but the extent to which it actually contributes to noise reduction in the patient care environment and in turn improves staff performance has not been previously documented. A before-and-after comparison was conducted in an adult cardiac ICU. The ICU was relocated from a traditional hospital environment to a new addition with a dedicated service corridor. A total of 118 nursing staff participated in the surveys regarding pre-move and post-move environmental comfort, stress, and satisfaction in the previous and new units. Acoustical measures of noise within the new ICU and a control environment of the previous unit were collected during four work days, along with on-site observations of corridor traffic. Independent and paired sample t-tests of survey data showed that the perceived noise level was lower and staff reported less stress and more satisfaction in the new ICU (p < 0.01). Analyses of acoustical data confirmed that the new ICU was significantly quieter (p < 0.02). Observations revealed how the service corridor impacted patient care services and traffic. The addition of a dedicated service corridor works in the new unit for improving noise control and staff stress and satisfaction. Critical care/intensive care, noise, satisfaction, staff, work environment.

The direct costs of intensive care management and risk factors for financial burden of patients with severe sepsis and septic shock.

PubMed

Khwannimit, Bodin; Bhurayanontachai, Rungsun

2015-10-01

The costs of severe sepsis care from middle-income countries are lacking. This study investigated direct intensive care unit (ICU) costs and factors that could affect the financial outcomes. A prospective cohort study was conducted in the medical ICU of a tertiary referral university teaching hospital in Thailand. A total of 897 patients were enrolled in the study, with 683 (76.1%) having septic shock. Community-, nosocomial, and ICU-acquired infections were documented in 574, 282, and 41 patients, respectively. The median ICU costs per patient were $2716.5 ($1296.1-$5367.6) and $599.9 ($414.3-$948.6) per day. The ICU costs accounted for 64.7% of the hospital costs. In 2008 to 2011, the ICU costs significantly decreased by 40% from $3542.5 to $2124.9, whereas, the daily ICU costs decreased only 3.3% from $609.7 to $589.7. By multivariate logistic regression analysis, age, nosocomial or ICU infection, admission from the emergency department, number of organ failures, ICU length of stay, and fluid balance the first 72 hours were independently associated with ICU costs. The ICU costs of severe sepsis management significantly declined in our study. However, the ICU costs were a financial burden accounting for two thirds of the hospital costs. It is essential for intensivists to contribute a high standard of care within a restricted budget. Copyright © 2015 Elsevier Inc. All rights reserved.

Standardizing intensive care device data to enable secondary usages.

PubMed

Ingenerf, Josef; Kock, Ann-Kristin; Poelker, Marcel; Seidl, Konrad; Zeplin, Georg; Mersmann, Stefan; Handels, Heinz

2012-01-01

To represent medical device observations in a format that is consumable by clinical software, standards like HL7v3 and ISO/IEEE 11073 should be used jointly. This is demonstrated in a project with Dräger Medical GmbH focusing on their Patient Data Management System (PDMS) in intensive care, called Integrated Care Manager (ICM). Patient and device data of interest should be mapped to suitable formats to enable data exchange and decision support. Instead of mapping device data to target formats bilaterally we use a generic HL7v3 Refined Message Information Model (RMIM) with device specific parts adapted to ISO/IEEE 11073 DIM. The generality of the underlying model (based on Yuksel et al. [1]) allows the flexible inclusion of IEEE 11073 conformant device models of interest on the one hand and the generation of needed artifacts for secondary usages on the other hand, e.g. HL7 V2 messages, HL7 CDA documents like the Personal Health Monitoring Report (PHMR) or web services. Hence, once the medical device data are obtained in the RMIM format, it can quite easily be transformed into HL7-based standard interfaces through XSL transformations because these interfaces all have their building blocks from the same RIM. From there data can be accessed uniformly, e.g. as needed by Dräger´s decision support system SmartCare [2] for automated control and optimization of weaning from mechanical ventilation.

The experience of sleep deprivation in intensive care patients: findings from a larger hermeneutic phenomenological study.

PubMed

Tembo, Agness C; Parker, Vicki; Higgins, Isabel

2013-12-01

Sleep deprivation in critically ill patients has been well documented for more than 30 years. Despite the large body of literature, sleep deprivation remains a significant concern in critically ill patients in intensive care unit (ICU). This paper discusses sleep deprivation in critically ill patients as one of the main findings from a study that explored the lived experiences of critically ill patients in ICU with daily sedation interruption (DSI). Twelve participants aged between 20 and 76 years with an ICU stay ranging from three to 36 days were recruited from a 16 bed ICU in a large regional referral hospital in New South Wales (NSW), Australia. Participants were intubated, mechanically ventilated and subjected to daily sedation interruption during their critical illness in ICU. In-depth face to face interviews with the participants were conducted at two weeks after discharge from ICU. A second interview was conducted with eight participants six to eleven months later. Interviews were audio taped and transcribed. Data were analysed thematically. "Longing for sleep" and "being tormented by nightmares" capture the experiences and concerns of some of the participants. The findings suggest a need for models of care that seek to support restful sleep and prevent or alleviate sleep deprivation and nightmares. These models of care need to promote both quality and quantity of sleep in and beyond ICU and identify patients suffering from sleep deprivation to make appropriate referrals for treatment and support. Copyright © 2013 Elsevier Ltd. All rights reserved.

[Reimbursement of intensive care services in the German DRG system : Current problems and possible solutions].

PubMed

Riessen, R; Hermes, C; Bodmann, K-F; Janssens, U; Markewitz, A

2018-02-01

The reimbursement of intensive care and nursing services in the German health system is based on the diagnosis-related groups (G-DRG) system. Due to the lack of a central hospital planning, the G‑DRG system has become the most important influence on the development of the German health system. Compared to other countries, intensive care in Germany is characterized by a high number of intensive care beds, a low nurse-to-patient ratio, no official definition of the level of care, and a minimal available data set from intensive care units (ICUs). Under the given circumstances, a shortage of qualified intensive care nurses and physicians is currently the largest threat for intensive care in Germany. To address these deficiencies, we suggest the following measures: (1) Integration of ICUs into the levels of care which are currently developed for emergency centers at hospitals. (2) Mandatory collection of structured data sets from all ICUs including quality criteria. (3) A reform of intensive care and nursing reimbursement under consideration of adequate staffing in the individual ICU. (4) Actions to improve ICU staffing and qualification.

Protocols and Hospital Mortality in Critically ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study

PubMed Central

Sevransky, Jonathan E.; Checkley, William; Herrera, Phabiola; Pickering, Brian W.; Barr, Juliana; Brown, Samuel M; Chang, Steven Y; Chong, David; Kaufman, David; Fremont, Richard D; Girard, Timothy D; Hoag, Jeffrey; Johnson, Steven B; Kerlin, Mehta P; Liebler, Janice; O'Brien, James; O'Keefe, Terence; Park, Pauline K; Pastores, Stephen M; Patil, Namrata; Pietropaoli, Anthony P; Putman, Maryann; Rice, Todd W.; Rotello, Leo; Siner, Jonathan; Sajid, Sahul; Murphy, David J; Martin, Greg S

2015-01-01

Objective Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized intensive care units have superior patient outcomes compared with less highly protocolized intensive care units. Design Observational study in which participating intensive care units completed a general assessment and enrolled new patients one day each week. Setting and Patients 6179 critically ill patients across 59 intensive care units in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Interventions: None Measurements and Main Results The primary exposure was the number of intensive care unit protocols; the primary outcome was hospital mortality. 5809 participants were followed prospectively and 5454 patients in 57 intensive care units had complete outcome data. The median number of protocols per intensive care unit was 19 (IQR 15 to 21.5). In single variable analyses, there were no differences in intensive care unit and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in intensive care units with a high vs. low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p=0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between intensive care units with high vs. low numbers of protocols for lung protective ventilation in ARDS (47% vs. 52%; p=0.28) and for spontaneous breathing trials (55% vs. 51%; p=0.27). Conclusions Clinical protocols are highly prevalent in United States intensive care units. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality. PMID:26110488

Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial.

PubMed

Curtis, J Randall; Downey, Lois; Back, Anthony L; Nielsen, Elizabeth L; Paul, Sudiptho; Lahdya, Alexandria Z; Treece, Patsy D; Armstrong, Priscilla; Peck, Ronald; Engelberg, Ruth A

2018-05-26

Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication. To evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care. Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016. Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care. The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders. We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months. This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study. ClinicalTrials.gov identifier: NCT01933789.

Hospital-level changes in adult ICU bed supply in the United States

PubMed Central

Wallace, David J.; Seymour, Christopher W.; Kahn, Jeremy M.

2017-01-01

Objective Although the number of intensive care beds in the United States is increasing, little is known about the hospitals responsible for this growth. We sought to better characterize national growth in intensive care beds by identifying hospital-level factors associated with increasing numbers of intensive care beds over time. Design We performed a repeated-measures time series analysis of hospital-level intensive care bed supply using data from Centers for Medicare and Medicaid Services. Setting All United States acute care hospitals with adult intensive care beds over the years 1996 to 2011. Measurements & Main Results We described the number of beds, teaching status, ownership, intensive care occupancy and urbanicity for each hospital in each year of the study. We then examined the relationship between increasing intensive care beds and these characteristics, controlling for other factors. The study included 4,457 hospitals and 55,865 hospital-years. Overall, the majority of intensive care bed growth occurred in teaching hospitals (net +13,471 beds, 72.1% of total growth), hospitals with 250 or more beds (net +18,327 beds, 91.8% of total growth) and hospitals in the highest quartile of occupancy (net +10,157 beds, 54.0% of total growth). In a longitudinal multivariable model, larger hospital size, teaching status, and high intensive care occupancy were associated with subsequent-year growth. Furthermore, the effects of hospital size and teaching status were modified by occupancy: the greatest odds of increasing intensive care unit beds were in hospitals with 500 or more beds in the highest quartile of occupancy (adjusted OR: 18.9; 95% CI: 14.0 – 25.5; p<0.01) and large teaching hospitals in the highest quartile of occupancy (adjusted OR: 7.3; 95% CI: 5.3 – 9.9; p<0.01). Conclusions Increasingly, intensive care bed expansion in the United States is occurring in larger hospitals and teaching centers, particularly following a year with high intensive care unit occupancy. PMID:27661861

Nursing workload in public and private intensive care units

PubMed Central

Nogueira, Lilia de Souza; Koike, Karina Mitie; Sardinha, Débora Souza; Padilha, Katia Grillo; de Sousa, Regina Marcia Cardoso

2013-01-01

Objective This study sought to compare patients at public and private intensive care units according to the nursing workload and interventions provided. Methods This retrospective, comparative cohort study included 600 patients admitted to 4 intensive care units in São Paulo. The nursing workload and interventions were assessed using the Nursing Activities Score during the first and last 24 hours of the patient's stay at the intensive care unit. Pearson's chi-square test, Fisher's exact test, the Mann-Whitney test, and Student's t test were used to compare the patient groups. Results The average Nursing Activities Score upon admission to the intensive care unit was 61.9, with a score of 52.8 upon discharge. Significant differences were found among the patients at public and private intensive care units relative to the average Nursing Activities Score upon admission, as well as for 12 out of 23 nursing interventions performed during the first 24 hours of stay at the intensive care units. The patients at the public intensive care units exhibited a higher average score and overall more frequent nursing interventions, with the exception of those involved in the "care of drains", "mobilization and positioning", and "intravenous hyperalimentation". The groups also differed with regard to the evolution of the Nursing Activities Score among the total case series as well as the groups of survivors from the time of admission to discharge from the intensive care unit. Conclusion Patients admitted to public and private intensive care units exhibit differences in their nursing care demands, which may help managers with nursing manpower planning. PMID:24213086

Development and evaluation of an aged care specific Advance Care Plan.

PubMed

Silvester, William; Parslow, Ruth A; Lewis, Virginia J; Fullam, Rachael S; Sjanta, Rebekah; Jackson, Lynne; White, Vanessa; Hudson, Rosalie

2013-06-01

To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention. An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention. 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria. Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the resident's preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents' values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans. Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.

Postintensive care unit psychological burden in patients with chronic obstructive pulmonary disease and informal caregivers: A multicenter study.

PubMed

de Miranda, Sandra; Pochard, Frédéric; Chaize, Marine; Megarbane, Bruno; Cuvelier, Antoine; Bele, Nicolas; Gonzalez-Bermejo, Jesus; Aboab, Jérome; Lautrette, Alexandre; Lemiale, Virginie; Roche, Nicolas; Thirion, Marina; Chevret, Sylvie; Schlemmer, Benoit; Similowski, Thomas; Azoulay, Elie

2011-01-01

To determine the prevalence and risk factors of symptoms of anxiety, depression, and posttraumatic stress disorder-related symptoms in patients with chronic obstructive pulmonary disease and their relatives after an intensive care unit stay. Prospective multicenter study. Nineteen French intensive care units. One hundred twenty-six patients with chronic obstructive pulmonary disease who survived an intensive care unit stay and 102 relatives. None. Patients and relatives were interviewed at intensive care unit discharge and 90 days later to assess symptoms of anxiety and depression using Hospital Anxiety and Depression Scale (HADS) and posttraumatic stress disorder-related symptoms using the Impact of Event Scale (IES). At intensive care unit discharge, 90% of patients recollected traumatic psychological events in the intensive care unit. At day 90, we were able to conduct telephone interviews with 53 patients and 47 relatives. Hospital Anxiety and Depression Scale scores indicated symptoms of anxiety and depression in 52% and 45.5% of patients at intensive care unit discharge and in 28.3% and 18.9% on day 90, respectively. Corresponding prevalence in relatives were 72.2% and 25.7% at intensive care unit discharge and 40.4% and 14.9% on day 90, respectively. The Impact of Event Scale indicated posttraumatic stress disorder-related symptoms in 20.7% of patients and 29.8% of relatives on day 90. Peritraumatic dissociation assessed using the Peritraumatic Dissociative Experiences Questionnaire was independently associated with posttraumatic stress disorder-related symptoms in the patients and relatives. Previous intensive care unit experience and recollection of bothersome noise in the intensive care unit predicted posttraumatic stress disorder-related symptoms in the patients. Psychiatric symptoms were found to be common in a group of 126 patients with chronic obstructive pulmonary disease who survived an intensive care unit stay and their relatives at intensive care unit discharge and 90 days later. Peritraumatic dissociation at intensive care unit discharge was found to independently predict posttraumatic stress disorder-related symptoms in this sample of patients and relatives.

Nursing management and organizational ethics in the intensive care unit.

PubMed

Wlody, Ginger Schafer

2007-02-01

This article describes organizational ethics issues involved in nursing management of an intensive care unit. The intensive care team and medical center management have the dual responsibility to create an ethical environment in which to provide optimum patient care. Addressing organizational ethics is key to creating that ethical environment in the intensive care unit. During the past 15-20 yrs, increasing costs in health care, competitive markets, the effect of high technology, and global business changes have set the stage for business and healthcare organizational conflicts that affect the ethical environment. Studies show that critical care nurses experience moral distress and are affected by the ethical climate of both the intensive care unit and the larger organization. Thus, nursing moral distress may result in problems related to recruitment and retention of staff. Other issues with organizational ethics ramifications that may occur in the intensive care unit include patient safety issues (including those related to disruptive behavior), intensive care unit leadership style, research ethics, allocation of resources, triage, and other economic issues. Current organizational ethics conflicts are discussed, a professional practice model is described, and multidisciplinary recommendations are put forth.

Implementation of early intensive behavioural intervention for children with autism in Switzerland.

PubMed

Studer, Nadja; Gundelfinger, Ronnie; Schenker, Tanja; Steinhausen, Hans-Christoph

2017-01-21

There is a major gap between the US and most European countries regarding the implementation of early intensive behavioural intervention (EIBI) for children with autism. The present paper reports on the current status of EIBI in Switzerland and on the effectiveness of EIBI under clinical conditions in a Swiss pilot project. The paper combines a narrative report of the care system for children with autism in Switzerland and an initial evaluation of EIBI as implemented in the Department of Child and Adolescent Psychiatry, University of Zurich. The current situation of the implementation of EIBI for children with autism in Switzerland is characterized by marked deficits in its acceptance. Major reasons include insufficient governmental approval and lacking legal and financial support. In addition, ignorance among health care providers and educational professionals has contributed to this situation precluding that children with autism receive the most beneficial assistance. The authors have initiated and been working in an intervention centre offering EIBI for a decade and report on their experience with the implementation of EIBI. Based on their clinical practice, they document that EIBI also works efficiently under ordinary mental health service conditions. EIBI needs to be implemented more intensively in Switzerland. Although the effects of EIBI as implemented in Zurich are promising, the results are not as pronounced as under controlled research conditions.

Re-evaluating ethical concerns in planned emergency research involving critically ill patients: an interpretation of the guidance document from the United States Food and Drug Administration.

PubMed

Smischney, Nathan J; Onigkeit, James A; Hinds, Richard F; Nicholson, Wayne T

2015-01-01

U.S. federal regulations require that certain ethical elements be followed to protect human research subjects. The location and clinical circumstances of a proposed research study can differ substantially and can have significant implications for these ethical considerations. Both the location and clinical circumstances are particularly relevant for research in intensive care units (ICUs), where patients are often unable to provide informed consent to participate in a proposed research intervention. Our goal is to elaborate on the updated 2013 U.S. Food and Drug Administration (FDA) guidance document regarding an exemption from the requirement of obtaining informed consent from patients or their surrogates and to address certain elements within that document, thereby assisting clinicians in developing a framework for emergency research in accordance with the regulatory bodies at their own institutions and in the United States. Review of the 2011 and updated FDA guidance document on exemption from informed consent. The current process of obtaining informed consent within ICUs needs to be revisited, especially for research in which timely informed consent is not likely. In particular, the process of obtaining informed consent may not be appropriate or even ethical for critically ill patients in extremis who require an intervention for which there is no current acceptable standard of care and clinical equipoise exists. We provide clinicians with a viewpoint that further elaborates on the FDA guidance document. The viewpoints provided herein are those of the authors and are therefore inherently limited by the personal views of a selected few. Other clinicians or researchers may not interpret the FDA guidelines in a similar manner. Moreover, the discussion of a guideline document is a limitation in and of itself. The guidelines set forth by the FDA are precisely that-guidelines. Therefore, they may not be followed as outlined in the guidance document within one's own institution. Our goal is that, by elaborating on the guidelines for planned research involving human subjects in the ICU, institutional regulatory bodies may gain a better understanding in drafting their own document when faced with a clinician or a researcher who wishes to conduct planned research in an ICU. We believe that the interpretations provided will allow clinicians to safely undertake planned research in ICUs without endangering the main tenets of ethical research involving human participants. This research is needed for the advancement of care in the critically ill. Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

A key ecological trait drove the evolution of biparental care and monogamy in an amphibian.

PubMed

Brown, Jason L; Morales, Victor; Summers, Kyle

2010-04-01

Linking specific ecological factors to the evolution of parental care pattern and mating system is a difficult task of key importance. We provide evidence from comparative analyses that an ecological factor (breeding pool size) is associated with the evolution of parental care across all frogs. We further show that the most intensive form of parental care (trophic egg feeding) evolved in concert with the use of small pools for tadpole deposition and that egg feeding was associated with the evolution of biparental care. Previous research on two Peruvian poison frogs (Ranitomeya imitator and Ranitomeya variabilis) revealed similar life histories, with the exception of breeding pool size. This key ecological difference led to divergence in parental care patterns and mating systems. We present ecological field experiments that demonstrate that biparental care is essential to tadpole survival in small (but not large) pools. Field observations demonstrate social monogamy in R. imitator, the species that uses small pools. Molecular analyses demonstrate genetic monogamy in R. imitator, the first example of genetic monogamy in an amphibian. In total, this evidence constitutes the most complete documentation to date that a single ecological factor drove the evolution of biparental care and genetic and social monogamy in an animal.

All patient refined-diagnostic related group and case mix index in acute care palliative medicine.

PubMed

Lagman, Ruth L; Walsh, Declan; Davis, Mellar P; Young, Brett

2007-03-01

The All Patient Refined-Diagnostic Related Group (APR-DRG) is a modification of the traditional DRG that adds four classes of illness severity and four classes of mortality risk. The APR-DRG is a more accurate assessment of the complexity of care. When individuals with advanced illness are admitted to an acute inpatient palliative medicine unit, there may be a perception that they receive less intense acute care. Most of these patients, however, are multisymptomatic, have several comorbidities, and are older. For all patients admitted to the unit, a guide was followed by staff physicians to document clinical information that included the site(s) of malignancy, site(s) of metastases, disease complications, disease-related symptoms, and comorbidities. We then prospectively compared DRGs, APR-DRGs, and case mix index (CMI) from January 1-June 30, 2003, and February 1-July 31,2004, before and after the use of the guide. The overall mean severity of illness (ASOI) increased by 25% (P < 0.05). The mean CMI increased by 12% (P < 0.05). The average length of stay over the same period increased slightly from 8.97 to 9.56 days. Systematic documentation of clinical findings using a specific tool for patients admitted to an acute inpatient palliative medicine unit based on APR-DRG classifications captured a higher severity of illness and may better reflect resource utilization.

[Management of dysphagia in internal intensive-care medicine].

PubMed

Michels, G; Motzko, M; Weinert, M; Bruckner, M; Pfister, R; Guntinas-Lichius, O

2015-04-01

Physicians specializing in dysphagia are needed in modern intensive care medicine. Long-term intubation is associated with aspiration and swallowing disorders. Early and standardised dysphagia management should be initiated during a patient's stay on intensive care unit. A clinically experienced, interdisciplinary team is required to provide optimal care for critically ill patients with dysphagia. Intensive care physicians should therefore know about basics in dysphagiology.

Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial.

PubMed

Yoon, Jean; Chang, Evelyn; Rubenstein, Lisa V; Park, Angel; Zulman, Donna M; Stockdale, Susan; Ong, Michael K; Atkins, David; Schectman, Gordon; Asch, Steven M

2018-06-05

Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization. To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients. Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526). 5 U.S. Department of Veterans Affairs (VA) medical centers. Primary care patients at high risk for hospitalization who had a recent acute care episode. Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts. Utilization and costs (including intensive management program expenses) 12 months before and after randomization. 2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization. Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed. High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs. Veterans Health Administration Primary Care Services.

Respiratory support in patients with acute respiratory distress syndrome: an expert opinion.

PubMed

Chiumello, Davide; Brochard, Laurent; Marini, John J; Slutsky, Arthur S; Mancebo, Jordi; Ranieri, V Marco; Thompson, B Taylor; Papazian, Laurent; Schultz, Marcus J; Amato, Marcelo; Gattinoni, Luciano; Mercat, Alain; Pesenti, Antonio; Talmor, Daniel; Vincent, Jean-Louis

2017-09-12

Acute respiratory distress syndrome (ARDS) is a common condition in intensive care unit patients and remains a major concern, with mortality rates of around 30-45% and considerable long-term morbidity. Respiratory support in these patients must be optimized to ensure adequate gas exchange while minimizing the risks of ventilator-induced lung injury. The aim of this expert opinion document is to review the available clinical evidence related to ventilator support and adjuvant therapies in order to provide evidence-based and experience-based clinical recommendations for the management of patients with ARDS.

Children's Post-Traumatic Stress and the Role of Memory Following Admission to Intensive Care: A Review

ERIC Educational Resources Information Center

Dow, Belinda; Kenardy, Justin; Long, Deborah; Le Brocque, Robyne

2012-01-01

Although our understanding of children's psychological outcomes following intensive care lags significantly behind advances in medicine, there is a growing awareness that intensive care admission impacts children beyond the boundaries of physical well-being. Intensive care presents a variety of disease-related, treatment-related, and…

Rates of adult acute inpatients documented as at risk of refeeding syndrome by dietitians.

PubMed

Owers, Emma L; Reeves, Anneli I; Ko, Susan Y; Ellis, Aleshia K; Huxtable, Shannon L; Noble, Sally A; Porteous, Helen E; Newman, Eli J; Josephson, Christine A; Roth, Rachel A; Byrne, Clare E; Palmer, Michelle A

2015-02-01

Identification of Refeeding Syndrome (RFS) is vital for prevention and treatment of metabolic disturbances, yet no information exists that describes identification rates by dietitians in acute care. We aimed to describe rates and demographics of inpatients identified by dietitians as at-risk of RFS and factors associated with electrolyte levels post-dietetic assessment. Eligible participants were adult (≥ 18 yrs) acute care inpatients reviewed by dietitians between March 2012-February 2013 and not admitted to intensive care prior to first dietetic assessment. Patient information was sourced from medical charts. Chi-squared, t-tests and linear regression analyses were conducted. Of 1661 eligible inpatients (55%F, 65 ± 18 yrs), 9% (n = 151) were documented as at-risk of RFS in the first dietetic medical chart entry. On average, patients identified with RFS-risk had four days greater hospital stay, were 13 kg lighter, more likely classified SGA C (36% vs. 7%), and on a modified diet (52% vs. 35%) than non-RFS patients (p < 0.05). Very low and low electrolyte values occurred within seven days post-dietetic assessment in 7% and 52%, respectively, of inpatients with RFS-risk. Regression analysis showed that electrolyte supplementation was positively associated (β = 0.145-0.594), and number of RFS-related risk factors negatively associated (β = -0.044-0.122), with potassium, magnesium and phosphate levels within seven days post-dietetic assessment (p < 0.05). Nine percent of adult inpatients were documented as at-risk of RFS by dietitians. Identification of at-risk patients was in accordance with RFS guidelines. Electrolyte supplementation was positively associated with electrolyte levels post-assessment. Consistency of RFS-risk identification between dietitians requires determination. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

Occupational Variation in End-of-Life Care Intensity.

PubMed

Hyder, Joseph A; Haring, R Sterling; Sturgeon, Daniel; Gazarian, Priscilla K; Jiang, Wei; Cooper, Zara; Lipsitz, Stuart R; Prigerson, Holly G; Weissman, Joel S

2018-03-01

End-of-life (EOL) care intensity is known to vary by secular and geographic patterns. US physicians receive less aggressive EOL care than the general population, presumably the result of preferences shaped by work-place experience with EOL care. We investigated occupation as a source of variation in EOL care intensity. Across 4 states, we identified 660 599, nonhealth maintenance organization Medicare beneficiaries aged ≥66 years who died between 2004 and 2011. Linking death certificates, we identified beneficiaries with prespecified occupations: nurses, farmers, clergy, mortuary workers, homemakers, first-responders, veterinary workers, teachers, accountants, and the general population. End-of-life care intensity over the last 6 months of life was assessed using 5 validated measures: (1) Medicare expenditures, rates of (2) hospice, (3) surgery, (4) intensive care, and (5) in-hospital death. Occupation was a source of large variation in EOL care intensity across all measures, before and after adjustment for sex, education, age-adjusted Charlson Comorbidity Index, race/ethnicity, and hospital referral region. For example, absolute and relative adjusted differences in expenditures were US$9991 and 42% of population mean expenditure ( P < .001 for both). Compared to the general population on the 5 EOL care intensity measures, teachers (5 of 5), homemakers (4 of 5), farmers (4 of 5), and clergy (3 of 5) demonstrated significantly less aggressive care. Mortuary workers had lower EOL care intensity (4 of 5) but small numbers limited statistical significance. Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower EOL care intensity. These findings may inform patients and clinicians navigating choices around individual EOL care preferences.

Appropriateness of red blood cell transfusion in Australasian intensive care practice.

PubMed

French, Craig J; Bellomo, Rinaldo; Finfer, Simon R; Lipman, Jeffery; Chapman, Marianne; Boyce, Neil W

2002-11-18

To determine the incidence and appropriateness of use of allogenic packed red blood cell (RBC) transfusion in Australian and New Zealand intensive care practice. Intensive care units of 18 Australian and New Zealand hospitals: March 2001. Prospective, observational, multicentre study. All admissions to participating intensive care units were screened and all patients who received a transfusion of RBC were enrolled. The indications for transfusion were recorded and compared with Australian National Health and Medical Research Council guidelines. Transfusions conforming to these guidelines were deemed appropriate. RBC transfusion in intensive care and transfusion appropriateness. 1808 admissions to intensive care units were screened: 357 (19.8%) admissions (350 patients) received an RBC transfusion while in intensive care. Overall, 1464 RBC units were administered in intensive care on 576 transfusion days. The most common indications for transfusion were acute bleeding (60.1%; 880/1464) and diminished physiological reserve (28.9%; 423/1464). The rate of inappropriate transfusion was 3.0% (44/1464). Diminished physiological reserve with haemogloblin level > or = 100 g/L was the indication in 50% (22/44) of inappropriate transfusions; no indication was provided for 31% (15/44). The rate of inappropriate transfusion in Australian and New Zealand intensive care units in 2001 was remarkably low.

[Admission, discharge and triage guidelines for paediatric intensive care units in Spain].

PubMed

de la Oliva, Pedro; Cambra-Lasaosa, Francisco José; Quintana-Díaz, Manuel; Rey-Galán, Corsino; Sánchez-Díaz, Juan Ignacio; Martín-Delgado, María Cruz; de Carlos-Vicente, Juan Carlos; Hernández-Rastrollo, Ramón; Holanda-Peña, María Soledad; Pilar-Orive, Francisco Javier; Ocete-Hita, Esther; Rodríguez-Núñez, Antonio; Serrano-González, Ana; Blanch, Luis

2018-05-01

A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition. Copyright © 2017 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

Admission, discharge and triage guidelines for paediatric intensive care units in Spain.

PubMed

de la Oliva, Pedro; Cambra-Lasaosa, Francisco José; Quintana-Díaz, Manuel; Rey-Galán, Corsino; Sánchez-Díaz, Juan Ignacio; Martín-Delgado, María Cruz; de Carlos-Vicente, Juan Carlos; Hernández-Rastrollo, Ramón; Holanda-Peña, María Soledad; Pilar-Orive, Francisco Javier; Ocete-Hita, Esther; Rodríguez-Núñez, Antonio; Serrano-González, Ana; Blanch, Luis

2018-05-01

A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition. Copyright © 2017. Publicado por Elsevier España, S.L.U.

Lived experience of the intensive care unit for patients who experienced delirium.

PubMed

Whitehorne, Karen; Gaudine, Alice; Meadus, Robert; Solberg, Shirley

2015-11-01

Delirium is a common occurrence for patients in the intensive care unit and can have a profound and lasting impact on them. Few studies describe the experience of intensive care patients who have had delirium. To understand the lived experience of intensive care for critically ill patients who experienced delirium. The study participants consisted of 7 men and 3 women, 46 to 70 years old, who had delirium according to the Confusion Assessment Method for the Intensive Care Unit. The van Manen method of hermeneutic phenomenology was used, and data collection entailed audio recorded semistructured interviews. Four themes were detected: "I can't remember," "Wanting to make a connection," "Trying to get it straight," and "Fear and safety concerns." Nurses working in intensive care units need to assess patients for delirium, assess the mental status of patients who have delirium, and help patients and patients' families learn about and deal with the psychological effects of the intensive care unit experience. ©2015 American Association of Critical-Care Nurses.

Factors affecting experiences of intensive care patients in Turkey: patient outcomes in critical care setting.

PubMed

Demir, Yurdanur; Korhan, Esra Akin; Eser, Ismet; Khorshid, Leyla

2013-07-01

To determine the factors affecting a patient's intensive care experience. The descriptive study was conducted at an intensive care unit in the Aegean Region of Turkey, and comprised 158 patients who spent at least 48 hours at the unit between June and November 2009. A questionnaire form and the Intensive Care Experience Scale were used as data collection tools. SPSS 11.5 was used for statistical analysis of the data. Of the total, 86 (54.4%) patients related to the surgical unit, while 72 (45.5%) spent time at the intensive care unit. Most of the subjects (n=113; 71.5%) reported that they constantly experienced pain during hospitalisation. Patients receiving mechanical ventilation support and patients reporting no pain had significantly higher scores on the intensive care experience scale. Patients who reported pain remembered their experiences less than those having no pain. Interventions are needed to make the experiences of patients in intensive care more positive.

Does implementation matter if comprehension is lacking? A qualitative investigation into perceptions of advance care planning in people with cancer.

PubMed

Ugalde, Anna; O'Callaghan, Clare; Byard, Clem; Brean, Samantha; MacKay, Jenelle; Boltong, Anna; Davoren, Sondra; Lawson, Deborah; Parente, Phillip; Michael, Natasha; Livingston, Patricia

2018-05-11

While advance care planning holds promise, uptake is variable and it is unclear how well people engage with or comprehend advance care planning. The objective of this study was to explore how people with cancer comprehended advance care plans and examine how accurately advance care planning documentation represented patient wishes. This study used a qualitative descriptive design. Data collection comprised interviews and an examination of participants' existing advance care planning documentation. Participants included those who had any diagnosis of cancer with an advance care plan recorded: Refusal of Treatment Certificate, Statement of Choices, and/or Enduring Power of Attorney (Medical Treatment) at one cancer treatment centre. Fourteen participants were involved in the study. Twelve participants were female (86%). The mean age was 77 (range: 61-91), and participants had completed their advance care planning documentation between 8 and 72 weeks prior to the interview (mean 33 weeks). Three themes were evident from the data: incomplete advance care planning understanding and confidence, limited congruence for attitude and documentation, advance care planning can enable peace of mind. Complete advance care planning understanding was unusual; most participants demonstrated partial comprehension of their own advance care plan, and some indicated very limited understanding. Participants' attitudes and their written document congruence were limited, but advance care planning was seen as helpful. This study highlighted advance care planning was not a completely accurate representation of patient wishes. There is opportunity to improve how patients comprehend their own advance care planning documentation.

Does age influence the intensity of care in a managed care organization?

PubMed

Long, Michael J; Lescoe-Long, Mary

2005-01-01

The primary objective of this study was to determine whether an inverse relationship between age and the intensity of care prevailed in an elderly, functionally impaired population enrolled in a managed care organization. The secondary objective was to determine whether those who died during the study were treated more intensively than the survivors. A total of 278 enrollees in a managed care organization who were 75 years and over, had a severe functional disability, excessive hospital or Emergency Department use, volunteered to take part in a 2-year study. Seventy-seven clients died during the study. We calculated indices of outpatient care intensity and hospital care intensity for the study period. With minor exceptions, the results clearly show that, for this group of clients, the intensity of outpatient care was clearly, inversely related to age. The intensity of hospital care was also inversely related to age, thereby ruling out the hypothesis that it was being substituted for outpatient care. The results also clearly show that, for this population, those who died during the study period were treated more intensively than the survivors. We found strong support for our hypotheses. An investigation of the reasons for these findings was beyond the scope of our data.

Evaluating the past to improve the future - A qualitative study of ICU patients' experiences.

PubMed

Olsen, Kristin Dahle; Nester, Marit; Hansen, Britt Sætre

2017-12-01

The recovery period for patients who have been in an intensive care unitis often prolonged and suboptimal. Anxiety, depression and post-traumatic stress disorder are common psychological problems. Intensive care staff offer various types of intensive aftercare. Intensive care follow-up aftercare services are not standard clinical practice in Norway. The overall aim of this study is to investigate how adult patients experience theirintensive care stay their recovery period, and the usefulness of an information pamphlet. A qualitative, exploratory research with semi-structured interviews of 29 survivors after discharge from intensive care and three months after discharge from the hospital. Two main themes emerged: "Being on an unreal, strange journey" and "Balancing between who I was and who I am" Patients' recollection of their intensive care stay differed greatly. Continuity of care and the nurse's ability to see and value individual differences was highlighted. The information pamphlet helped intensive care survivors understand that what they went through was normal. Continuity of care and an individual approach is crucial to meet patients' uniqueness and different coping mechanisms. Intensive care survivors and their families must be included when information material and rehabilitation programs are designed and evaluated. Copyright © 2017 Elsevier Ltd. All rights reserved.

Impact of Medicare Advantage penetration and hospital competition on technical efficiency of nursing care in US intensive care units.

PubMed

Min, Ari; Scott, Linda D; Park, Chang; Vincent, Catherine; Ryan, Catherine J; Lee, Taewha

2018-04-10

This study aimed to evaluate technical efficiency of US intensive care units and determine the effects of environmental factors on technical efficiency in providing quality of nursing care. Data were obtained from the 2014 National Database of Nursing Quality Indicators and the Centers for Medicare and Medicaid Services. Data envelopment analysis was used to estimate technical efficiency for each intensive care unit. Multilevel modeling was used to determine the effects of environmental factors on technical efficiency. Overall, Medicare Advantage penetration and hospital competition in a market did not create pressure for intensive care units to become more efficient by reducing their inputs. However, these 2 environmental factors showed positive influences on technical efficiency in intensive care units with certain levels of technical efficiency. The implications of the study results for management strategies and health policy may vary according to the levels of technical efficiency in intensive care units. Further studies are needed to examine why and how intensive care units with particular levels of technical efficiency are differently affected by certain environmental factors. Copyright © 2018 John Wiley & Sons, Ltd.

Assessment of delirium using the PRE-DELIRIC model in an intensive care unit in Argentina

PubMed Central

Sosa, Fernando Ariel; Roberti, Javier; Franco, Margarita Tovar; Kleinert, María Mercedes; Patrón, Agustina Risso; Osatnik, Javier

2018-01-01

Objective To describe the incidence of and risk factors for delirium in the intensive care unit of a tertiary care teaching hospital in Argentina and to conduct the first non-European study exploring the performance of the PREdiction of DELIRium in ICu patients (PRE-DELIRIC) model. Methods Prospective observational study in a 20-bed intensive care unit of a tertiary care teaching hospital in Buenos Aires, Argentina. The PRE-DELIRIC model was applied to 178 consecutive patients within 24 hours of admission to the intensive care unit; delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Results The mean age was 64.3 ± 17.9 years. The median time of stay in the intensive care unit was 6 (range, 2 - 56) days. Of the total number of patients, 49/178 (27.5%) developed delirium, defined as a positive CAM-ICU assessment, during their stay in the intensive care unit. Patients in the delirium group were significantly older and had a significantly higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score. The mortality rate in the intensive care unit was 14.6%; no significant difference was observed between the two groups. Predictive factors for the development of delirium were increased age, prolonged intensive care unit stay, and opioid use. The area under the curve for the PRE-DELIRIC model was 0.83 (95%CI; 0.77 - 0.90). Conclusions The observed incidence of delirium highlights the importance of this problem in the intensive care unit setting. In this first study conducted outside Europe, PRE-DELIRIC accurately predicted the development of delirium. PMID:29742219

Standardised care plans for in hospital stroke care improve documentation of health care assessments.

PubMed

Pöder, Ulrika; Dahm, Marie Fogelberg; Karlsson, Nina; Wadensten, Barbro

2015-10-01

To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record. Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital. Quantitative, comparative. Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record. Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged. An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis. Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety. © 2015 John Wiley & Sons Ltd.

Analysis of family satisfaction in intensive care unit.

PubMed

Neves, Flávia Branco Cerqueira Serra; Dantas, Maíra Pereira; Bitencourt, Almir Galvão Vieira; Vieira, Patrícia Sena; Magalhães, Lis Thomazini; Teles, José Mário Meira; Farias, Augusto Manoel de Carvalho; Messeder, Octávio Henrique Coelho

2009-03-01

To know the needs and level of family members' satisfaction is an essential part of the care provided to critically ill patients in intensive care units. The objective of this study was to identify the level of family members' satisfaction in an intensive care unit. A descriptive survey was carried out in the general adult intensive care unit of the Hospital Português (Salvador - BA) from November 2007 to January 2008. Jonhson's 14-question modified version of the Critical Care Family Needs Inventory was used to evaluate satisfaction of family members. Fifty three family members were included, mean age was 44 years and 68% were female. The median of family members satisfaction level was 11 (IQI = 9-13). Critical Care Family Need Inventory, questions with higher percentiles of satisfaction were those stating that family members felt that the patient was receiving the best possible care (96%) and that the information provided was honest (96%). The questions with lower percentiles of satisfaction were those stating that family members believed that someone in the intensive care unit had shown interest in their feelings (45%) and that a healthcare professional had explained how the intensive care unit equipment was used (41%). Most family members positively evaluated the intensive care unit professionals in the questions related to communication, attitude and patient care. However, there was a lower level of satisfaction in the questions related to the intensive care unit professionals' ability to comfort family members.

[Update: studies in intensive care medicine. Results of the last 12 months].

PubMed

Knapp, J; Marx, G; Weismüller, K; Steinebach, S; Lichtenstern, C; Popp, E; Mayer, K; Brunkhorst, F M; Weigand, M A; Bernhard, M

2011-11-01

Intensive care medicine plays an important role in the medical care of patients as well as the economic success of hospitals. Knowledge and implementation of recent relevant scientific evidence are prerequisites for high quality care in intensive care medicine. The aim of this review is to present an overview of the most important publications in intensive care medicine published in 2010 and the first half of the year 2011 and to comment on their attributable clinical relevance for intensive care practitioners. In 2010 and up to June 2011 many studies with high patient numbers have been published. The main topics were the treatment of respiratory failure, sepsis and investigations to improve analgosedation.

'In a dark place, we find ourselves': light intensity in critical care units.

PubMed

Durrington, Hannah J; Clark, Richard; Greer, Ruari; Martial, Franck P; Blaikley, John; Dark, Paul; Lucas, Robert J; Ray, David W

2017-12-01

Intensive care units provide specialised care for critically ill patients around the clock. However, intensive care unit patients have disrupted circadian rhythms. Furthermore, disrupted circadian rhythms are associated with worse outcome. As light is the most powerful 're-setter' of circadian rhythm, we measured light intensity on intensive care unit. Light intensity was low compared to daylight during the 'day'; frequent bright light interruptions occurred over 'night'. These findings are predicted to disrupt circadian rhythms and impair entrainment to external time. Bright lighting during daytime and black out masks at night might help maintain biological rhythms in critically ill patients and improve clinical outcomes.

Intensity of Care at the End of Life Among Older Adults in Korea.

PubMed

Kim, Su Hyun; Kang, Sangwook; Song, Mi-Kyung

2018-01-01

To examine the intensity of care at the end of life among older adults in Korea and to identify the individual and institutional factors associated with care intensity. This secondary data analysis included a sample of 6278 decedents aged 65 years or older who were identified from the 2009 to 2010 Korean National Health Insurance Service-National Sample Cohort Claims data. We examined the medical care received by the cohort in the last 30 days of their lives. Overall, 36.5% of the sample received at least 1 intensive care procedure in the last 30 days of their lives; 26.3% of patients experienced intensive care unit admission, with an average stay of 7.45 days, 19.5% received mechanical ventilation, 12.3% received cardiopulmonary resuscitation, and 15.5% had a feeding tube placement. A statistical analysis using a multiple logistic regression model with random effects showed that younger age, higher household income, primary diagnoses of diseases (ischemic heart disease, infectious disease, chronic lung disease, or chronic heart disease), and characteristics of care setting (large hospitals and facilities located in metropolitan areas) were significantly associated with the likelihood of receiving high-intensity care at the end of life. A substantial number of older adults in Korea experienced high-intensity end-of-life care. Both individual and institutional factors were associated with the likelihood of receiving high-intensity care. Gaining an understanding of the intensity of care at the end of life and the impact of the determinants would advance efforts to improve quality of care at the end of life for older adults in Korea.

Funding Intensive Care - Approaches in Systems Using Diagnosis-Related Groups.

PubMed

Ettelt, Stefanie; Nolte, Ellen

2012-01-01

This article summarizes a review of approaches to funding intensive care in health systems that use activity-based payment mechanisms based on diagnosis-related groups (DRGs) to reimburse hospital care in Australia (Victoria), Denmark, France, Germany, Italy, Spain, Sweden and the United States (Medicare). The study aims to inform the current debate about options for funding intensive care services for adults, children and newborns in England. Mechanisms of funding intensive care services tend to fall into three broad categories: (1) those that fund intensive care through DRGs as part of one episode of hospital care only (US Medicare, Germany, selected regions in Sweden and Italy; (2) those that use DRGs in combination with co-payments (Victoria, France); and (3) those that exclude intensive care from DRG funding and use an alternative form of payment, for example global budgets (Spain) or per diems (South Australia). The review suggests that there is no obvious example of "best practice" or dominant approach used by a majority of systems. Each approach has advantages and disadvantages, particularly in relation to the financial risk involved in providing intensive care. While the risk of underfunding intensive care may be highest in systems that apply DRGs to the entire episode of hospital care, including intensive care, concerns about potential underfunding were voiced in all systems reviewed here. Arrangements for additional funding in the form of co-payments or surcharges may reduce the risk of underfunding. However, these approaches also face the difficulty of determining the appropriate level of (additional) payment and balancing the incentive effect arising from higher payment.

Improving social work in intensive care unit palliative care: results of a quality improvement intervention.

PubMed

McCormick, Andrew J; Curtis, J Randall; Stowell-Weiss, Patti; Toms, Carol; Engelberg, Ruth

2010-03-01

The intensive care unit (ICU) is a focal point for decision making in end-of-life care. Social workers are involved in providing this care for patients and families. Our goal was to examine the social worker component of an intervention to improve interdisciplinary palliative care in the ICU. The study took place at a 350-bed hospital with 65 ICU beds. We surveyed family members and social workers caring for patients who died in the ICU or within 30 hours of transfer from ICU. Clustered regression was used to assess the effect of the intervention on three outcomes: (1) families' satisfaction with social work, (2) social workers' reported palliative and supportive activities, and (3) social workers' satisfaction with meeting family needs. Of 590 eligible patients, 275 families completed surveys (response rate, 47%). Thirty-five social workers received 353 questionnaires concerning 353 unique patients and completed 283 (response rate, 80%). Social workers reported significant increase in the total number of activities for family members after the intervention. Some of the activities included addressing spiritual or religious needs, discussing disagreement among the family, and assuring family the patient would be kept comfortable. Neither social workers' satisfaction with meeting families' needs nor family ratings of social workers were higher after the intervention. Increased social worker experience and smaller social worker caseload were both associated with increased family satisfaction with social work. The increase in social worker-reported activities supports the value of the interdisciplinary intervention, but we did not demonstrate improvements in other outcomes. Increased social-worker experience and decreased social worker caseload were independently associated with better family ratings of social workers suggesting future directions for interventions to improve care by social workers. Future studies will need more powerful interventions or more sensitive outcome measures to document improvements in family-assessed outcomes.

The Family Navigator: A Pilot Intervention to Support Intensive Care Unit Family Surrogates.

PubMed

Torke, Alexia M; Wocial, Lucia D; Johns, Shelley A; Sachs, Greg A; Callahan, Christopher M; Bosslet, Gabriel T; Slaven, James E; Perkins, Susan M; Hickman, Susan E; Montz, Kianna; Burke, Emily S

2016-11-01

Communication problems between family surrogates and intensive care unit (ICU) clinicians have been documented, but few interventions are effective. Nurses have the potential to play an expanded role in ICU communication and decision making. To conduct a pilot randomized controlled trial of the family navigator (FN), a distinct nursing role to address family members' unmet communication needs early in an ICU stay. An interprofessional team developed the FN protocol. A randomized controlled pilot intervention trial of the FN was performed in a tertiary referral hospital's ICU to test the feasibility and acceptability of the intervention. The intervention addressed informational and emotional communication needs through daily contact by using structured clinical updates, emotional and informational support modules, family meeting support, and follow-up phone calls. Twenty-six surrogate/patient pairs (13 per study arm) were enrolled. Surrogates randomized to the intervention had contact with the FN on 90% or more of eligible patient days. All surrogates agreed that they would recom mend the FN to other families. Open-ended comments from both surrogates and clinicians were uniformly positive. Having a fully integrated nurse empowered to facilitate decision making is a feasible intervention in an ICU and is well-received by ICU families and staff. A larger randomized controlled trial is needed to demonstrate impact on important outcomes, such as surrogates' well-being and decision quality. ©2016 American Association of Critical-Care Nurses.

Molecular typing and whole genome next generation sequencing of human adenovirus 8 strains recovered from four 2012 outbreaks of keratoconjunctivitis in New York State.

PubMed

Lamson Bs, Daryl M; Kajon, Adriana E; Shudt, Matthew; Quinn, Monica; Newman, Alexandra; Whitehouse, Joan; Greenko, Jane; Adams, Eleanor; St George, Kirsten

2018-05-11

Ocular infections caused by human adenovirus (HAdV) are highly contagious. The most severe are usually caused by members of species HAdV-D (types HAdV8, 19, 37, 53, 54, and 56) and can manifest as epidemic keratoconjunctivitis (EKC), often resulting in prolonged impairment of vision. During the early months of 2012, EKC outbreaks occurred in neonatal intensive care units (NICUs) in 3 hospitals in New York State (New York and Suffolk Counties). A total of 32 neonates were affected. For 14 of them, HAdV8 was laboratory-confirmed as the causative agent. Nine healthcare workers were also affected with 3 laboratory-confirmed, HAdV-positive EKC. A fourth EKC outbreak was documented among patients attending a private ophthalmology practice in Ulster County involving a total of 35 cases. Epidemiological linkage between the neonatal intensive care unit outbreaks was demonstrated by molecular typing of virus isolates with restriction enzyme analysis and next generation whole genome sequencing. The strain isolated from the ophthalmology clinic was easily distinguishable from the others by restriction enzyme analysis. © 2018 Wiley Periodicals, Inc.

Flavobacterium sepsis outbreak due to contaminated distilled water in a neonatal intensive care unit.

PubMed

Mosayebi, Z; Movahedian, A H; Soori, T

2011-07-01

Outbreaks of sepsis due to water or contaminated equipment can cause significant mortality and morbidity in neonatal intensive care units. We studied an outbreak among neonates caused by flavobacterium and investigated the characteristics of the infected neonates, antimicrobial susceptibilities, and the source of the outbreak. Forty-five neonates with documented flavobacterium sepsis were evaluated in this descriptive study. Data including sex, vaginal delivery or caesarean, preterm or term, birth weight, results of blood cultures and antibiograms were recorded and cases followed up until death or recovery. Environmental sampling for detecting the source of contamination was performed. Among the 45 patients, 28 (62.2%) were male and 17 (37.8%) female (P<0.001). The commonest clinical manifestation was respiratory distress (60%). Eighteen neonates (40%) were low birth weight. Thirty-seven neonates (82.2%) were born via caesarean section. Twenty (44.4%) of them were preterm whereas 25 (55.6%) were term (P<0.001). Mortality was 17.7%. All strains were resistant to ampicillin, and susceptible to amikacin. The source of outbreak was contaminated distilled water. Copyright © 2010 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Prevalence and quality of clinical pathways in Swedish intensive care units: a national survey.

PubMed

Bjurling-Sjöberg, Petronella; Jansson, Inger; Wadensten, Barbro; Engström, Gabriella; Pöder, Ulrika

2014-02-01

To identify the prevalence of clinical pathways (CPs) in Swedish intensive care units (ICUs) and to explore the quality, content and evidence base of the documents. A descriptive and explorative survey of all Swedish ICUs (N84) and a review of submitted examples of CPs (n12) were conducted. CPs were in use at 20% of the Swedish ICUs. There was a significant geographic variation but no relationship between the use of CPs and category of hospital, type of ICU, size of ICU or type of health record applied. In total, 56 CPs were reported within a range of scopes and extensions. The content of the ICUs' CPs, as well as the degree to which they were interprofessional, evidence based, and renewed varied. Progress has been made in relation to CPs in recent years, but there is potential for further improvements. None of the ICUs had CPs that contained all key characteristics of a high-quality, interprofessional and evidence-based CP identified in the literature. Greater knowledge sharing and cooperation within the field would be beneficial, and further research is needed. © 2013 John Wiley & Sons, Ltd.

Potential palliative care quality indicators in heart disease patients: A review of the literature.

PubMed

Mizuno, Atsushi; Miyashita, Mitsunori; Hayashi, Akitoshi; Kawai, Fujimi; Niwa, Koichiro; Utsunomiya, Akemi; Kohsaka, Shun; Kohno, Takashi; Yamamoto, Takeshi; Takayama, Morimasa; Anzai, Toshihisa

2017-10-01

In spite of the increasing interest in palliative care for heart disease, data on the detailed methods of palliative care and its efficacy specifically in heart disease are still lacking. A structured PubMed literature review revealed no quality indicators of palliative care in heart disease. Therefore, we performed a narrative overview of the potential quality indicators in heart disease by reviewing previous literature concerning quality indicators in cancer patients. We summarize seven potential categories of quality indicators in heart disease: (1) presence and availability of a palliative care unit, palliative care team, and outpatient palliative care; (2) human resources such as number of skilled staff; (3) infrastructure; (4) presence and frequency of documentation or family survey; (5) patient-reported outcome measure (PROM) data and disease-specific patient quality of life such as The Kansas City Cardiomyopathy Questionnaire (KCCQ); (6) questionnaires and interviews about the quality of palliative care after death, including bereaved family surveys; and (7) admission-related outcomes such as place of death and intensive care unit length of stay. Although detailed measurements of palliative care quality have not been validated in heart disease, many indicators developed in cancer patients might also be applicable to heart disease. This new categorization might be useful to determine quality indicators in heart disease patients. Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

First Clinical Consensus and National Recommendations on Tracheostomized Children of the Brazilian Academy of Pediatric Otorhinolaryngology (ABOPe) and Brazilian Society of Pediatrics (SBP).

PubMed

Avelino, Melissa A G; Maunsell, Rebecca; Valera, Fabiana Cardoso Pereira; Lubianca Neto, José Faibes; Schweiger, Cláudia; Miura, Carolina Sponchiado; Chen, Vitor Guo; Manrique, Dayse; Oliveira, Raquel; Gavazzoni, Fabiano; Picinin, Isabela Furtado de Mendonça; Bittencourt, Paulo; Camargos, Paulo; Peixoto, Fernanda; Brandão, Marcelo Barciela; Sih, Tania Maria; Anselmo-Lima, Wilma Terezinha

Tracheostomy is a procedure that can be performed in any age group, including children under 1year of age. Unfortunately health professionals in Brazil have great difficulty dealing with this condition due to the lack of standard care orientation. This clinical consensus by Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) and Sociedade Brasileira de Pediatria (SBP) aims to generate national recommendations on the care concerning tracheostomized children. A group of experts experienced in pediatric tracheostomy (otorhinolaryngologists, intensive care pediatricians, endoscopists, and pediatric pulmonologists) were selected, taking into account the different regions of Brazil and following inclusion and exclusion criteria. The results generated from this document were based on the agreement of the majority of participants regarding the indications, type of cannula, surgical techniques, care, and general guidelines and decannulation. These guidelines can be used as directives for a wide range of health professionals across the country that deal with tracheostomized children. Copyright © 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Compared to Palliative Care, Working in Intensive Care More than Doubles the Chances of Burnout: Results from a Nationwide Comparative Study

PubMed Central

Teixeira, Carla Margarida; Carvalho, Ana Sofia; Hernández-Marrero, Pablo

2016-01-01

Introduction Professionals working in intensive and palliative care units, hence caring for patients at the end-of-life, are at risk of developing burnout. Workplace conditions are determinant factors to develop this syndrome among professionals providing end-of-life care. Objectives To identify and compare burnout levels between professionals working in intensive and palliative care units; and to assess which workplace experiences are associated with burnout. Methods A nationwide, multicentre quantitative comparative survey study was conducted in Portugal using the following instruments: Maslach Burnout Inventory–Human Services Survey, Questionnaire of workplace experiences and ethical decisions, and Questionnaire of socio-demographic and professional characteristics. A total of 355 professionals from 10 intensive care and 9 palliative care units participated in the survey. A series of univariate and multivariate logistic regression analyses were performed; odds ratio sidelong with 95% confidence intervals were calculated. Results 27% of the professionals exhibited burnout. This was more frequent in intensive care units (OR = 2.525, 95% CI: 1.025–6.221, p = .006). Univariate regression analyses showed that higher burnout levels were significantly associated with conflicts, decisions to withhold/withdraw treatment, and implementing palliative sedation. When controlling for socio-demographic and educational characteristics, and setting (intensive care units versus palliative care units), higher burnout levels were significantly and positively associated with experiencing conflicts in the workplace. Having post-graduate education in intensive/palliative care was significantly but inversely associated to higher burnout levels. Conclusions Compared to palliative care, working in intensive care units more than doubled the likelihood of exhibiting burnout. Experiencing conflicts (e.g., with patients and/or families, intra and/or inter-teams) was the most significant determinant of burnout and having post-graduate education in intensive/palliative care protected professionals from developing this syndrome. This highlights the need for promoting empowering workplace conditions, such as team empowerment and conflict management. Moreover, findings suggest the need for implementing quality improvement strategies and organizational redesign strategies aimed at integrating the philosophy, principles and practices of palliative care in intensive care units. PMID:27612293

Turning whine into wine: the fiscal impact of comprehensive documentation and billing for nonoperative pediatric surgical services.

PubMed

Gollin, Gerald; Moores, Donald

2006-06-01

Some pediatric surgeons rarely document nonoperative services, believing that the reimbursement provided for such care is negligible. We evaluated the impact of comprehensive documentation and billing for nonoperative, pediatric surgical care. All bills submitted for inpatient, nonoperative care for 1 year were reviewed. Total receipts for documented admissions, consultations, critical care, and daily care were determined. The Evaluation and Management code billed for each service was recorded, and the total and average payments attributable to each Evaluation and Management code were calculated. Fifty-six percent of services were covered by Medicaid and 26% by a commercial insurer. There were 607 billed admission history and physical exams for which reimbursement totaled 43,493 dollars. Critical care services were provided to 49 patients and yielded 8964 dollars in payments. Six hundred thirty-nine inpatient consultations were performed with a reimbursement of 42,830 dollars. Daily care services were billed 1044 times and produced 71,579 dollars in payments. Overall reimbursement for documented, nonoperative services was 166,866 dollars. This represented 16.2% of total, noncontracted income for the practice. Despite a payer mix heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what it would have been had only operative services been billed. The yield from properly documented, nonoperative care can be substantial.

Heavy physician workloads: impact on physician attitudes and outcomes.

PubMed

Williams, Eric S; Rondeau, Kent V; Xiao, Qian; Francescutti, Louis H

2007-11-01

The intensity of physician workload has been increasing with the well-documented changes in the financing, organization and delivery of care. It is possible that these stressors have reached a point where they pose a serious policy issue for the entire healthcare system through their diminution of physician's ability to effectively interact with patients as they are burned out, stressed and dissatisfied. This policy question is framed in a conceptual model linking workloads with five key outcomes (patient care quality, individual performance, absenteeism, turnover and organizational performance) mediated by physician stress and satisfaction. This model showed a good fit to the data in a structural equation analysis. Ten of the 12 hypothesized pathways between variables were significant and supported the mediating role of stress and satisfaction. These results suggest that workloads, stress and satisfaction have significant and material impacts on patient care quality, individual performance, absenteeism, turnover and organizational performance. Implications of these results and directions for future research are discussed.

Proprietary and voluntary home care agency evolution: the emergence of a new entity.

PubMed

Balinsky, W; Shames, J N

1985-01-01

The objective of this paper is to document that the delivery of home care services and the corresponding ways in which they are marketed are evolving in both proprietary and voluntary providers. This evolution is producing the emergency of a new entity. In order to examine the present state, it is necessary to review the general history of the development of both voluntary (not-for-profit) and proprietary home health services. Then, an analysis of present conditions will show that these two forms of ownership are changing in ways that are making them more alike than different. This situation is leading to more intense competition for an expanding and diverse mix of home services. Program content and corresponding marketing techniques have crossed the industry's traditional lines blending into a wide array of services being offered by both voluntary and proprietary organizations. Despite their many shared goals and objectives, home care agencies still differ in their underlying philosophy which is based at least in part on their past.

Palliative sedation: the position statement of the Italian National Committee for Bioethics.

PubMed

Orsi, Luciano; Gristina, Giuseppe R

2017-05-01

In January 2016 the Italian National Bioethics Committee (NBC) published a position statement entitled Deep and continuous palliative sedation in the imminence of death, related to the use of sedation and analgesia for relief from pain and psychological distress in dying patients. In this statement the Committee points out the clinical and ethical appropriateness of palliative sedation as a therapeutic procedure. As a result, today palliative sedation has to be considered useful, scientifically safe and reliable, and acknowledged as an integral part of good clinical practice. At the same time, the position statement, once and for all, makes clear that palliative sedation cannot and must not be equated with the practice of euthanasia. Thus, this document should be known by health professionals caring for dying patients not only in palliative as well as in intensive care settings, but it should be also considered as a milestone aimed to encourage and ease a widespread implementation of this procedure in all health care settings.

Valuing Individuals' Preferences and Health Choices of Physical Exercise.

PubMed

Aboagye, Emmanuel

2017-06-01

The efficacy of physical exercise for the prevention and treatment of non-specific low back pain (LBP) is well documented, but little is known about how individuals value specific components of physical exercise, such as the type and design or the intensity and frequency of exercise. Other factors that influence individual differences in health choices and adherence are associated with individuals' attitudes toward and likelihood of performing recommended exercise regimens. Current evidence shows that efficacy is similar among exercise interventions, but their features vary widely. Thus it may be difficult for clinicians to discriminate between available options in clinical practice. Considering the many challenges in determining the form of exercise best suited to the individual patient, this commentary discusses some of the practical methods that could be used to elicit individual preference for recommended health care interventions. Such methods have the advantage of providing more information for health care decision making, particularly with regard to exercise interventions for LBP. This commentary also advocates for the use of patient preference in health care decisions.

Nurses' perceptions of the impact of electronic health records on work and patient outcomes.

PubMed

Kossman, Susan P; Scheidenhelm, Sandra L

2008-01-01

This study addresses community hospital nurses' use of electronic health records and views of the impact of such records on job performance and patient outcomes. Questionnaire, interview, and observation data from 46 nurses in medical-surgical and intensive care units at two community hospitals were analyzed. Nurses preferred electronic health records to paper charts and were comfortable with technology. They reported use of electronic health records enhanced nursing work through increased information access, improved organization and efficiency, and helpful alert screens. They thought use of the records hindered nursing work through impaired critical thinking, decreased interdisciplinary communication, and a high demand on work time (73% reported spending at least half their shift using the records). They thought use of electronic health records enabled them to provide safer care but decreased the quality of care. Administrative implications include involving bedside nurses in system choice, streamlining processes, developing guidelines for consistent documentation quality and location, increasing system speed, choosing hardware that encourages bedside use, and improving system information technology support.

Assessing Nursing Care Needs of Children With Complex Medical Conditions: The Nursing-Kids Intensity of Care Survey (N-KICS).

PubMed

Navarra, Ann-Margaret; Schlau, Rona; Murray, Meghan; Mosiello, Linda; Schneider, Laura; Jackson, Olivia; Cohen, Bevin; Saiman, Lisa; Larson, Elaine L

2016-01-01

Recent medical advances have resulted in increased survival of children with complex medical conditions (CMC), but there are no validated methods to measure their care needs. To design and test the Nursing-Kids Intensity of Care Survey (N-KICS) tool and describe intensity of nursing care for children with CMC. The psychometric evaluation confirmed an acceptable standard for reliability and validity and feasibility. Intensity scores were highest for nursing care related to infection control, medication administration, nutrition, diaper changes, hygiene, neurological and respiratory support, and standing program. Development of a psychometrically sound measure of nursing intensity will help evaluate and plan nursing care for children with CMC. Copyright © 2016 Elsevier Inc. All rights reserved.

Assessing Nursing Care Needs of Children with Complex Medical Conditions: The Nursing Kids Intensity of Care Survey (N-KICS)

PubMed Central

Navarra, Ann-Margaret; Schlau, Rona; Murray, Meghan; Mosiello, Linda; Schneider, Laura; Jackson, Olivia; Cohen, Bevin; Saiman, Lisa; Larson, Elaine L.

2015-01-01

Background Recent medical advances have resulted in increased survival of children with complex medical conditions (CMC), but there are no validated methods to measure their care needs. Objectives/Methods To design and test the Nursing-Kids Intensity of Care Survey (N-KICS) tool and describe intensity of nursing care for children with CMC. Results The psychometric evaluation confirmed an acceptable standard for reliability and validity and feasibility. Intensity scores were highest for nursing care related to infection control, medication administration, nutrition, diaper changes, hygiene, neurological and respiratory support, and standing program. Conclusions Development of a psychometrically sound measure of nursing intensity will help evaluate and plan nursing care for children with CMC. PMID:26777429

What drives perceived work intensity in neonatal intensive care units? Empirical evidence from a longitudinal study.

PubMed

Sülz, Sandra; Langhammer, Kristina; Becker-Peth, Michael; Roth, Bernhard

2017-10-01

To investigate the drivers of perceived work intensity among neonatal intensive care unit nurses. The consequences of high work intensity have been studied extensively, yet setting-specific drivers have received less attention. Prospective, longitudinal and monocentric study design. The study combined data from standardized diary surveys and passive observations of study nurses. Data were collected over a period of 6 months in 2015. We considered two scenarios: (1) the perception of normal work intensity relative to non-normal work intensity; and (2) the perception of high work intensity relative to non-high work intensity. Perceived work intensity was then analysed using mixed-effects probit regression models. We found that when direct and indirect care were provided more frequently than administrative and other duties were performed, the evaluated nurses perceived their work intensity to be higher. We also found that nurses who more frequently provided care for sick and preterm infants were less likely to perceive their work intensity as normal and this effect was stronger among nurses who cared for infants under mechanical ventilation than nurses who cared for infants receiving non-invasive respiratory support. In the interest of both nurses and infants and the pursuit of a reduction in perceived work intensity and the provision of better neonatal care, caution must be applied when assigning infants to nurses. Further research is needed to validate these findings using a multicentre study design. © 2017 John Wiley & Sons Ltd.

Assessment of parental presence during bedside pediatric intensive care unit rounds: effect on duration, teaching, and privacy.

PubMed

Phipps, Lorri M; Bartke, Cheryl N; Spear, Debra A; Jones, Linda F; Foerster, Carolyn P; Killian, Marie E; Hughes, Jennifer R; Hess, Joseph C; Johnson, David R; Thomas, Neal J

2007-05-01

There is a paucity of literature evaluating the effects of family member presence during bedside medical rounds in the pediatric intensive care unit. We hypothesized that, when compared with rounds without family members, parental presence during morning medical rounds would increase time spent on rounds, decrease medical team teaching/education, increase staff dissatisfaction, create more stress in family members, and violate patient privacy in our open unit. Prospective, blinded, observational study. Academic pediatric intensive care unit with 12 beds. A total of 105 admissions were studied, 81 family members completed a survey, and 187 medical team staff surveys were completed. Investigators documented parental presence and time allocated for presentation, teaching, and answering questions. Surveys related to perception of goals, teaching, and privacy of rounds were distributed to participants. Time spent on rounds, time spent teaching on rounds, and medical staff and family perception of the effects of parental presence on rounds. There was no significant difference between time spent on rounds in the presence or absence of family members (p = NS). There is no significant difference between the time spent teaching by the attending physician in the presence or absence of family members (p = NS). Overall, parents reported that the medical team spent an appropriate amount of time discussing their child and were not upset by this discussion. Parents did not perceive that their own or their child's privacy was violated during rounds. The majority of medical team members reported that the presence of family on rounds was beneficial. Parental presence on rounds does not seem to interfere with the educational and communication process. Parents report satisfaction with participation in rounds, and privacy violations do not seem to be a concern from their perspective.

Promotion of prescription drugs to consumers.

PubMed

Rosenthal, Meredith B; Berndt, Ernst R; Donohue, Julie M; Frank, Richard G; Epstein, Arnold M

2002-02-14

Spending on prescription drugs is the fastest growing component of the health care budget. There is public concern about the possibility that direct-to-consumer advertising of prescription drugs will result in inappropriate prescribing and higher costs of care. Guidelines issued in 1997 by the Food and Drug Administration (FDA) regarding advertising to consumers through electronic media are considered by some to be responsible for unleashing a flood of direct-to-consumer advertising. Using data on spending for promotional purposes and sales of prescription drugs, we examined industrywide trends for various types of promotion. We also tracked the relation between promotional efforts and sales over time. Finally, we documented the variation in direct-to-consumer advertising among and within five therapeutic classes of drugs and compared the variation in the intensity of such advertising with variation in the intensity of promotion to health care professionals. Annual spending on direct-to-consumer advertising for prescription drugs tripled between 1996 and 2000, when it reached nearly $2.5 billion. Despite this increase, such advertising accounts for only 15 percent of the money spent on drug promotion and is highly concentrated on a subgroup of products. Within a therapeutic class, there is marked variation in the intensity of direct-to-consumer advertising, and the amount of such advertising for specific products fluctuates over time. The initial surge in direct-to-consumer advertising preceded the 1997 FDA guidelines that clarified the rules for electronic direct-to-consumer advertising, and thus the 1997 guidelines may not have been the most important reason for the overall increase. Although the use of direct-to-consumer advertising has grown disproportionately to other forms of promotion, it continues to account for a small proportion of total promotional efforts. Nevertheless, physicians must assist patients in evaluating health-related information obtained through direct advertising.

Dexmedetomidine infusion as adjunctive therapy to benzodiazepines for acute alcohol withdrawal.

PubMed

Darrouj, Jamil; Puri, Nitin; Prince, Erin; Lomonaco, Anthony; Spevetz, Antoinette; Gerber, David R

2008-11-01

To report a case of alcohol withdrawal and delirium tremens successfully treated with adjunctive dexmedetomidine. A 30-year-old man with a history of alcohol abuse was admitted to the general medical unit because of altered mental status and agitation. He was initially treated for alcohol withdrawal with benzodiazepines; his condition then deteriorated and he was transferred to the intensive care unit. Because of the patient's poor response to benzodiazepines (oxazepam and lorazepam, with midazolam the last one used), intravenous dexmedetomidine was started at an initial dose of 0.2 microg/kg/h and titrated to 0.7 microg/kg/h to the patient's comfort. Midazolam was subsequently tapered to discontinuation due to excessive sedation. In the intensive care unit, the patient's symptoms remained controlled with use of dexmedetomidine alone. He remained in the intensive care unit for 40 hours; dexmedetomidine was then tapered to discontinuation and the patient was transferred back to the general medical unit on oral oxazepam and thiamine, which had been started in the emergency department. He was discharged after 5 days. A review of the PubMed database (1989-2007) failed to identify any other instances of dexmedetomidine having been used as the principal agent to treat alcohol withdrawal. The use of sedative to treat delirium tremens is well documented, with benzodiazepines being the agents of choice. The clinical utility of benzodiazepines is limited by their stimulation of the gamma-aminobutyric acid receptors, an effect not shared by dexmedetomidine, a central alpha(2)-receptor agonist that induces a state of cooperative sedation and does not suppress respiratory drive. In patients with delirium tremens, dexmedetomidine should be considered as an option for primary treatment. This case illustrates the need for further studies to investigate other potential uses for dexmedetomidine.

Sensitivity and specificity of a screening test to document traumatic experiences and to diagnose post-traumatic stress disorder in ARDS patients after intensive care treatment.

PubMed

Stoll, C; Kapfhammer, H P; Rothenhäusler, H B; Haller, M; Briegel, J; Schmidt, M; Krauseneck, T; Durst, K; Schelling, G

1999-07-01

Many survivors of critical illness and intensive care unit (ICU) treatment have traumatic memories such as nightmares, panic or pain which can be associated with the development of posttraumatic stress disorder (PTSD). In order to simplify the rapid and early detection of PTSD in such patients, we modified an existing questionnaire for diagnosis of PTSD and validated the instrument in a cohort of ARDS patients after long-term ICU therapy. Follow-up cohort study. The 20-bed ICU of a university teaching hospital. A cohort of 52 long-term survivors of the acute respiratory distress syndrome (ARDS). The questionnaire was administered to the study cohort at two time points 2 years apart. At the second evaluation, the patients underwent a structured interview with two trained psychiatrists to diagnose PTSD according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. The reliability and validity of the questionnaire was then estimated and its specificity, sensitivity and optimal decision threshold determined using receiver operating characteristic (ROC) curve analyses. The questionnaire showed a high internal consistency (Crohnbach's alpha = 0.93) and a high test-retest reliability (intraclass correlation coefficient alpha = 0.89). There was evidence of construct validity by a linear relationship between scores and the number of traumatic memories from the ICU the patients described (Spearman's rho = 0.48, p < 0.01). Criterion validity was demonstrated by ROC curve analyses resulting in a sensitivity of 77.0% and a specificity of 97.5% for the diagnosis of PTSD. The questionnaire was found to be a responsive, valid and reliable instrument to screen survivors of intensive care for PTSD.

'Targeting' sedation: the lived experience of the intensive care nurse.

PubMed

Everingham, Kirsty; Fawcett, Tonks; Walsh, Tim

2014-03-01

To discuss the findings from a phenomenological study that provides insights into the intensive care nurses' 'world' following changes in the sedation management of patients in an intensive care unit. Intensive care sedation practices have undergone significant changes. Patients, where possible, are now managed on lighter levels of sedation, often achieved through the performance of sedation holds (SHs). The performance of SHs is normally carried out by the bedside nurse but compliance is reported to be poor. There has been little exploration of the nurses' experiences of these changes and the implications of SHs and subsequent wakefulness on their delivery of care. Following ethical approval, 16 intensive care nurses, experienced and inexperienced, from within a general intensive care unit. A Heideggerian phenomenological approach was used. Data collection consisted of interviews guided by an aide memoir and a framework adapted from Van Manen informed the analysis. The findings reveal new insights into the world of the intensive care nurse in the light of the changes to sedation management. They demonstrate that there have been unforeseen outcomes from well-intentioned initiatives to improve the quality of patients' care. There were implications from the changes introduced for the nurses care delivery. The main themes that emerged were 'working priorities' and 'unintended consequences', in turn revealing embedded tensions between evidence-based targets and holistic care. Intensive care nurses find that the current approach to the changes in sedation management can threaten their professional obligation and personal desire to provide holistic care. The 'targeted' approach by healthcare organisations is perceived to militate against the patient-centred care they want to deliver. Sedation management is complex and needs further consideration particularly the potential constraints 'target-led' care has on nursing practice. © 2013 Blackwell Publishing Ltd.

Intensive Care in Critical Access Hospitals

ERIC Educational Resources Information Center

Freeman, Victoria A.; Walsh, Joan; Rudolf, Matthew; Slifkin, Rebecca T.; Skinner, Asheley Cockrell

2007-01-01

Context: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. Purpose: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of…

The impact of 24-hr, in-hospital pediatric critical care attending physician presence on process of care and patient outcomes*.

PubMed

Nishisaki, Akira; Pines, Jesse M; Lin, Richard; Helfaer, Mark A; Berg, Robert A; Tenhave, Thomas; Nadkarni, Vinay M

2012-07-01

Attending physicians are only required to provide in-hospital coverage during daytime hours in many pediatric intensive care units. An in-hospital 24-hr pediatric intensive care unit attending coverage model has been increasingly popular, but the impact of 24-hr, in-hospital attending coverage on care processes and outcomes has not been reported. We compared processes of care and outcomes before and after the implementation of a 24-hr in-hospital pediatric intensive care unit attending physician model. Retrospective comparison of before and after cohorts. A single large, academic tertiary medical/surgical pediatric intensive care unit. : Pediatric intensive care unit admissions in 2000-2006. Transition to 24-hr from 12-hr in-hospital pediatric critical care attending physician coverage model in January 2004. A total of 18,702 patients were admitted to intensive care unit: 8,520 in 24 hrs; 10,182 in 12 hrs. Duration of mechanical ventilation was lower (median 33 hrs [interquartile range 12-88] vs. 48 hrs [interquartile range 16-133], adjusted reduction of 35% [95% confidence interval 25%-44%], p < .001) and intensive care unit length of stay was shorter (median 2 days [interquartile range 1-4] vs. 2 days [interquartile range 1-5], adjusted p < .001) for 24 hr vs. 12 hr coverage. The reduction in mechanical ventilation hours was similar when noninvasive, mechanical ventilation was included in ventilation hours (median 42 hrs vs. 56 hrs, adjusted reduction in ventilation hours: 33% [95% confidence interval 20-45], p < .001). Intensive care unit mortality was not significantly different (2.2% vs. 2.5%, adjusted p =.23). These associations were consistent across daytime and nighttime admissions, weekend and weekday admissions, and among subgroups with higher Pediatric Risk of Mortality III scores, postsurgical patients, and histories of previous intensive care unit admission. Implementation of 24-hr in-hospital pediatric critical care attending coverage was associated with shorter duration of mechanical ventilation and shorter length of intensive care unit stay. After accounting for potential confounders, this finding was consistent across a broad spectrum of critically ill children.

Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study.

PubMed

Henrich, Natalie J; Dodek, Peter M; Gladstone, Emilie; Alden, Lynn; Keenan, Sean P; Reynolds, Steven; Rodney, Patricia

2017-07-01

Moral distress is common among personnel in the intensive care unit, but the consequences of this distress are not well characterized. To examine the consequences of moral distress in personnel in community and tertiary intensive care units in Vancouver, Canada. Data for this study were obtained from focus groups and analysis of transcripts by themes and sub-themes in 2 tertiary care intensive care units and 1 community intensive care unit. According to input from 19 staff nurses (3 focus groups), 4 clinical nurse leaders (1 focus group), 13 physicians (3 focus groups), and 20 other health professionals (3 focus groups), the most commonly reported emotion associated with moral distress was frustration. Negative impact on patient care due to moral distress was reported 26 times, whereas positive impact on patient care was reported 11 times and no impact on patient care was reported 10 times. Having thoughts about quitting working in the ICU was reported 16 times, and having no thoughts about quitting was reported 14 times. In response to moral distress, health care providers experience negative emotional consequences, patient care is perceived to be negatively affected, and nurses and other health care professionals are prone to consider quitting working in the intensive care unit. ©2017 American Association of Critical-Care Nurses.

Determining Fuzzy Membership for Sentiment Classification: A Three-Layer Sentiment Propagation Model

PubMed Central

Zhao, Chuanjun; Wang, Suge; Li, Deyu

2016-01-01

Enormous quantities of review documents exist in forums, blogs, twitter accounts, and shopping web sites. Analysis of the sentiment information hidden in these review documents is very useful for consumers and manufacturers. The sentiment orientation and sentiment intensity of a review can be described in more detail by using a sentiment score than by using bipolar sentiment polarity. Existing methods for calculating review sentiment scores frequently use a sentiment lexicon or the locations of features in a sentence, a paragraph, and a document. In order to achieve more accurate sentiment scores of review documents, a three-layer sentiment propagation model (TLSPM) is proposed that uses three kinds of interrelations, those among documents, topics, and words. First, we use nine relationship pairwise matrices between documents, topics, and words. In TLSPM, we suppose that sentiment neighbors tend to have the same sentiment polarity and similar sentiment intensity in the sentiment propagation network. Then, we implement the sentiment propagation processes among the documents, topics, and words in turn. Finally, we can obtain the steady sentiment scores of documents by a continuous iteration process. Intuition might suggest that documents with strong sentiment intensity make larger contributions to classification than those with weak sentiment intensity. Therefore, we use the fuzzy membership of documents obtained by TLSPM as the weight of the text to train a fuzzy support vector machine model (FSVM). As compared with a support vector machine (SVM) and four other fuzzy membership determination methods, the results show that FSVM trained with TLSPM can enhance the effectiveness of sentiment classification. In addition, FSVM trained with TLSPM can reduce the mean square error (MSE) on seven sentiment rating prediction data sets. PMID:27846225

Quantifying the improvement in sepsis diagnosis, documentation, and coding: the marginal causal effect of year of hospitalization on sepsis diagnosis.

PubMed

Jafarzadeh, S Reza; Thomas, Benjamin S; Marschall, Jonas; Fraser, Victoria J; Gill, Jeff; Warren, David K

2016-01-01

To quantify the coinciding improvement in the clinical diagnosis of sepsis, its documentation in the electronic health records, and subsequent medical coding of sepsis for billing purposes in recent years. We examined 98,267 hospitalizations in 66,208 patients who met systemic inflammatory response syndrome criteria at a tertiary care center from 2008 to 2012. We used g-computation to estimate the causal effect of the year of hospitalization on receiving an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code for sepsis by estimating changes in the probability of getting diagnosed and coded for sepsis during the study period. When adjusted for demographics, Charlson-Deyo comorbidity index, blood culture frequency per hospitalization, and intensive care unit admission, the causal risk difference for receiving a discharge code for sepsis per 100 hospitalizations with systemic inflammatory response syndrome, had the hospitalization occurred in 2012, was estimated to be 3.9% (95% confidence interval [CI], 3.8%-4.0%), 3.4% (95% CI, 3.3%-3.5%), 2.2% (95% CI, 2.1%-2.3%), and 0.9% (95% CI, 0.8%-1.1%) from 2008 to 2011, respectively. Patients with similar characteristics and risk factors had a higher of probability of getting diagnosed, documented, and coded for sepsis in 2012 than in previous years, which contributed to an apparent increase in sepsis incidence. Copyright © 2016 Elsevier Inc. All rights reserved.

Work environment for Chinese nurses in different types of ICUs: a multisite cross-sectional survey.

PubMed

Bai, Jinbing; Zhang, Qing; Wang, Ying; Yu, Li-Ping; Pei, Xian-Bo; Cheng, Lei; Hsu, Lily

2015-05-01

To investigate the current nurse work environment, levels of job satisfaction and quality of patient care, and to identify intensive care units with a healthier work environment in mainland China. A healthy work environment is closely related to a higher nurse job satisfaction and a better patient care quality. The work environment has not been extensively explored among Chinese intensive care unit nurses. The Chinese version of the Essentials of Magnetism II was used to measure the nurse work environment and another two 0-10 single-item scales were used to assess nurses' overall job satisfaction and nurse-assessed quality of care. The study found that the eight essentials of Chinese version of the Essentials of Magnetism II were significantly correlated with each other and also correlated with overall job satisfaction and quality of care. Nurses from medical intensive care units had a healthier work environment with higher scores of overall job satisfaction and quality of care than other intensive care units, while surgical intensive care units showed the least healthy work environment with the lowest overall job satisfaction and quality of care scores identified. The essentials of Chinese version of the Essentials of Magnetism II, overall job satisfaction and quality of care were also correlated with nurses' work experience and their education level. Nurse administrators and health policy-makers should establish a healthy work environment for intensive care units nurses, especially for those from surgical intensive care units. © 2014 John Wiley & Sons Ltd.

Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit?

PubMed

Bartley, Judene; Streifel, Andrew J

2010-08-01

We review the context of the environment of care in the intensive care unit setting in relation to patient safety and quality, specifically addressing healthcare-associated infection issues and solutions involving interdisciplinary teams. Issues addressed include current and future architectural design and layout trends, construction trends affecting intensive care units, and prevention of construction-associated healthcare-associated infections related to airborne and waterborne risks and design solutions. Specific elements include single-occupancy, acuity-scalable intensive care unit rooms; environmental aspects of hand hygiene, such as water risks, sink design/location, human waste management, surface selection (floor covering, countertops, furniture, and equipment) and cleaning, antimicrobial-treated or similar materials, ultraviolet germicidal irradiation, specialized rooms (airborne infection isolation and protective environments), and water system design and strategies for safe use of potable water and mitigation of water intrusion. Effective design and operational use of the intensive care unit environment of care must engage critical care personnel from initial planning and design through occupancy of the new/renovated intensive care unit as part of the infection control risk assessment team. The interdisciplinary infection control risk assessment team can address key environment of care design features to enhance the safety of intensive care unit patients, personnel, and visitors. This perspective will ensure the environment of care supports human factors and behavioral aspects of the interaction between the environment of care and its occupants.

Using the Delphi method to develop nursing-sensitive quality indicators for the NICU.

PubMed

Chen, Lin; Huang, Li-Hua; Xing, Mei-Yuan; Feng, Zhi-Xian; Shao, Le-Wen; Zhang, Mei-Yun; Shao, Rong-Ya

2017-02-01

To develop nursing-sensitive quality indicators consistent with current medical practices in Chinese neonatal intensive care units. The development of nursing-sensitive quality indicators has become a top priority in nursing management. To the best of our knowledge, there has been no objective, scientific and sensitive evaluation of the quality of neonatal intensive care unit nursing in China. A modified Delphi technique was used to seek opinions from experts about what should be used and prioritised as indicators of quality care in neonatal intensive care unit nursing. Based on a literature review, we identified 21 indicators of nursing-sensitive quality in the neonatal intensive care unit. Our group of 11 consultants chose 13 indicators to be discussed using the Delphi method. In October and November 2014, 39 neonatal intensive care unit experts in 18 tertiary hospitals spread across six provinces participated in two rounds of Delphi panels. Of the 13 indicators discussed, 11 were identified as indicators of nursing-sensitive quality in the neonatal intensive care unit: rate of nosocomial infections, rate of accidental endotracheal extubation, rate of errors in medication administration, rate of treatment for pain, rate of peripheral venous extravasation, rate of compliance with handwashing techniques, incidence of pressure ulcers, incidence of noise, the bed-to-care ratio, the proportion of nurses with greater than five years neonatal intensive care unit experience and incidence of retinopathy. The 11 neonatal intensive care unit nursing-sensitive indicators identified by the Delphi method integrated with basic Chinese practices provide a basis for nursing management and the monitoring of nursing quality. This study identified nursing-sensitive quality indicators for neonatal intensive care unit care that are suitable for current clinical practice in China. © 2016 John Wiley & Sons Ltd.

Assessing Emotional Suffering in Palliative Care: Use of a Structured Note Template to Improve Documentation.

PubMed

Lamba, Sangeeta; Berlin, Ana; Goett, Rebecca; Ponce, Christopher B; Holland, Bart; Walther, Susanne

2016-07-01

Documentation of the emotional or psychological needs of seriously ill patients receiving specialty palliative care is endorsed by the "Measuring What Matters" project as a quality performance metric and recommended for use by hospice and palliative care programs for program improvement. The aim of this study was to increase the proportion of inpatient palliative care team encounters in which emotional or psychological needs of patients and family members were documented and to qualitatively enrich the nature of this documentation. This is a mixed-methods retrospective study of 200 patient charts reviewed before and after implementation of a structured note template (SmartPhrase) for palliative care encounters. Patterns of documentation of emotional needs pre- and post-implementation were assessed quantitatively and qualitatively using thematic analysis. A total of 158 of 200 pre-intervention charts and 185 of 200 post-intervention charts included at least one note from the palliative care team. Documentation of emotional assessment increased after SmartPhrase implementation (63.9% [101 of 158] vs. 74.6% [138 of 185]; P < 0.03). Qualitative analysis revealed a post-intervention reduction in the use of generic phrases ("emotional support provided") and an increase in the breadth and depth of emotion-related documentation. A structured note template with a prompt for emotional assessment increases the overall quantity and richness of documentation related to patient and family emotions. However, this documentation remains mostly descriptive. Additional prompting for documentation of recommendations to address identified emotional needs, and the use of screening tools for depression and anxiety, when appropriate, may be necessary for clinically meaningful quality improvements in patient care. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

A nurse-led intensive care after-care programme - development, experiences and preliminary evaluation.

PubMed

Samuelson, Karin A M; Corrigan, Ingrid

2009-01-01

The benefits of critical care follow-up services include increased understanding of the long-term consequences of intensive care and entail helping patients and their next of kin to come to terms with their problems and distress following critical illness and intensive care treatment. To establish an intensive care after-care programme and to conduct a preliminary evaluation of the follow-up service from the patients' and relatives' perspectives in a general intensive care unit (ICU) in Sweden. A descriptive and evaluative design was used, and data from the first year of the after-care programme were collected. The final programme was nurse led and included five main points; a patient diary with colour photographs, ward visits, a patient information pamphlet, a follow-up consultation 2-3 months after intensive care discharge and feedback to the ICU staff. An evaluation questionnaire was handed out to patients and next of kin attending the follow-up clinic, e.g. asking the respondents to rate their satisfaction of the consultation on a visual analogue scale (VAS). The first year of after-care statistics showed that 170 survivors with a stay of 48 h or more were discharged from the ICU, resulting in 190 ward visits and 79 follow-up consultations. The preliminary evaluation revealed that the 2-month follow-up consultation achieved a median VAS rating of 9.8 (ranging from 1 to 10, poor to excellent) from both patients and next of kin. The development and preliminary evaluation of this nurse-led intensive care programme resulted in a feasible programme, requiring modest resources, with a high level of patient and relative satisfaction. This paper attempts to share with professional colleagues important steps during the developmental process of establishing an intensive care follow-up service and presents the content and preliminary evaluation of a nurse-led intensive care after-care programme focusing on the patients' and relatives' perspectives.

Market variations in intensity of Medicare service use and beneficiary experiences with care.

PubMed

Mittler, Jessica N; Landon, Bruce E; Fisher, Elliot S; Cleary, Paul D; Zaslavsky, Alan M

2010-06-01

Examine associations between patient experiences with care and service use across markets. Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index. We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets. We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid. Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care. Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.

Effectiveness of osteopathic manipulative treatment in neonatal intensive care units: protocol for a multicentre randomised clinical trial

PubMed Central

Cerritelli, Francesco; Pizzolorusso, Gianfranco; Renzetti, Cinzia; D'Incecco, Carmine; Fusilli, Paola; Perri, Paolo Francesco; Tubaldi, Lucia; Barlafante, Gina

2013-01-01

Introduction Neonatal care has been considered as one of the first priorities for improving quality of life in children. In 2010, 10% of babies were born prematurely influencing national healthcare policies, economic action plans and political decisions. The use of complementary medicine has been applied to the care of newborns. One previous study documented the positive effect of osteopathic manipulative treatment (OMT) in reducing newborns’ length of stay (LOS). Aim of this multicentre randomised controlled trial is to examine the association between OMT and LOS across three neonatal intensive care units (NICUs). Methods and analysis 690 preterm infants will be recruited from three secondary and tertiary NICUs from north and central Italy and allocated into two groups, using permuted-block randomisation. The two groups will receive standard medical care and OMT will be applied, twice a week, to the experimental group only. Outcome assessors will be blinded of study design and group allocation. The primary outcome is the mean difference in days between discharge and entry. Secondary outcomes are difference in daily weight gain, number of episodes of vomit, regurgitation, stooling, use of enema, time to full enteral feeding and NICU costs. Statistical analyses will take into account the intention-to-treat method. Missing data will be handled using last observation carried forward (LOCF) imputation technique. Ethics and dissemination Written informed consent will be obtained from parents or legal guardians at study enrolment. The trial has been approved by the ethical committee of Macerata hospital (n°22/int./CEI/27239) and it is under review by the other regional ethics committees. Results Dissemination of results from this trial will be through scientific medical journals and conferences. Trial registration This trial has been registered at http://www.clinicaltrials.org (identifier NCT01645137). PMID:23430598

Communication and Decision-Making About End-of-Life Care in the Intensive Care Unit.

PubMed

Brooks, Laura Anne; Manias, Elizabeth; Nicholson, Patricia

2017-07-01

Clinicians in the intensive care unit commonly face decisions involving withholding or withdrawing life-sustaining therapy, which present many clinical and ethical challenges. Communication and shared decision-making are key aspects relating to the transition from active treatment to end-of-life care. To explore the experiences and perspectives of nurses and physicians when initiating end-of-life care in the intensive care unit. The study was conducted in a 24-bed intensive care unit in Melbourne, Australia. An interpretative, qualitative inquiry was used, with focus groups as the data collection method. Intensive care nurses and physicians were recruited to participate in a discipline-specific focus group. Focus group discussions were audio-recorded, transcribed, and subjected to thematic data analysis. Five focus groups were conducted; 17 nurses and 11 physicians participated. The key aspects discussed included communication and shared decision-making. Themes related to communication included the timing of end-of-life care discussions and conducting difficult conversations. Implementation and multidisciplinary acceptance of end-of-life care plans and collaborative decisions involving patients and families were themes related to shared decision-making. Effective communication and decision-making practices regarding initiating end-of-life care in the intensive care unit are important. Multidisciplinary implementation and acceptance of end-of-life care plans in the intensive care unit need improvement. Clear organizational processes that support the introduction of nurse and physician end-of-life care leaders are essential to optimize outcomes for patients, family members, and clinicians. ©2017 American Association of Critical-Care Nurses.

Accuracy of healthcare worker recall and medical record review for identifying infectious exposures to hospitalized patients.

PubMed

Aquino, M; Raboud, J M; McGeer, A; Green, K; Chow, R; Dimoulas, P; Loeb, M; Scales, D

2006-07-01

To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting. Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall. A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario. Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts. Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient-HCW pairs were not recorded in patients' medical records. Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.

Rapid Deployment of International Tele-Intensive Care Unit Services in War-Torn Syria.

PubMed

Moughrabieh, Anas; Weinert, Craig

2016-02-01

The conflict in Syria has created the largest humanitarian emergency of the twenty-first century. The 4-year Syrian conflict has destroyed hospitals and severely reduced the capacity of intensive care units (ICUs) and on-site intensivists. The crisis has triggered attempts from abroad to support the medical care of severely injured and acutely ill civilians inside Syria, including application of telemedicine. Within the United States, tele-ICU programs have been operating for more than a decade, albeit with high start-up costs and generally long development times. With the benefit of lessons drawn from those domestic models, the Syria Tele-ICU program was launched in December 2012 to manage the care of ICU patients in parts of Syria by using inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. At the end of 2015, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The volunteer clinicians manage patients at a distance of more than 6,000 miles, separated by seven or eight time zones between North America and Syria. The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country.

Rapid Deployment of International Tele–Intensive Care Unit Services in War-Torn Syria

PubMed Central

Moughrabieh, Anas

2016-01-01

The conflict in Syria has created the largest humanitarian emergency of the twenty-first century. The 4-year Syrian conflict has destroyed hospitals and severely reduced the capacity of intensive care units (ICUs) and on-site intensivists. The crisis has triggered attempts from abroad to support the medical care of severely injured and acutely ill civilians inside Syria, including application of telemedicine. Within the United States, tele-ICU programs have been operating for more than a decade, albeit with high start-up costs and generally long development times. With the benefit of lessons drawn from those domestic models, the Syria Tele-ICU program was launched in December 2012 to manage the care of ICU patients in parts of Syria by using inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. At the end of 2015, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The volunteer clinicians manage patients at a distance of more than 6,000 miles, separated by seven or eight time zones between North America and Syria. The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country. PMID:26788827

Improved clinical outcomes combining house staff self-assessment with an audit-based quality improvement program.

PubMed

Kirschenbaum, Linda; Kurtz, Susannah; Astiz, Mark

2010-10-01

There is a focus on integrating quality improvement with medical education and advancement of the American College of Graduate Medical Education (ACGME) core competencies. To determine if audits of patients with unexpected admission to the medical intensive care unit using a self-assessment tool and a focused Morbidity and Mortality (M&M) conference improves patient care. Charts from patients transferred from the general medical floor (GMF) to the medical intensive care unit (ICU) were reviewed by a multidisciplinary team. Physician and nursing self-assessment tools and a targeted monthly M&M conference were part of the educational component. Physicians and nurses participated in root cause analysis. Records of all patients transferred from a general medical floor (GMF) to the ICU were audited. One hundred ninety-four cases were reviewed over a 10-month period. New policies regarding vital signs and house staff escalation of care were initiated. The percentage of calls for patients who met medical emergency response team/critical care consult criteria increased from 53% to 73%, nurse notification of a change in a patient's condition increased from 65% to 100%, nursing documentation of the change in the patients condition and follow-up actions increased from 65% percent to a high of 90%, the number of cardiac arrests on a GMF decreased from 3.1/1,000 discharges to 0.6/1,000 discharges (p = 0.002), and deaths on the Medicine Service decreased from 34/1,000 discharges to 24/1,000 discharges (p = 0.024). We describe an audit-based program that involves nurses, house staff, a self-assessment tool and a focused M&M conference. The program resulted in significant policy changes, more rapid assessment of unstable patients and improved hospital outcomes.

Beyond Pain: Nurses' Assessment of Patient Suffering, Dignity, and Dying in the Intensive Care Unit.

PubMed

Su, Amanda; Lief, Lindsay; Berlin, David; Cooper, Zara; Ouyang, Daniel; Holmes, John; Maciejewski, Renee; Maciejewski, Paul K; Prigerson, Holly G

2018-06-01

Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients' experiences at the end of life in the ICU. The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity. From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients' experiences. Medical chart abstraction was used to document baseline patient characteristics and care. The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P < 0.05) associated with suffering, after adjusting for physical pain, including fever/chills, fatigue, and edema. Most patients received vasopressors and mechanical ventilation. Renal replacement therapy was significantly (<0.05) associated with severe suffering (adjusted odds ratio [AOR] 2.53) and loss of dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12). Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Effects of interdisciplinary teamwork on patient-reported experience of cancer care.

PubMed

Tremblay, Dominique; Roberge, Danièle; Touati, Nassera; Maunsell, Elizabeth; Berbiche, Djamal

2017-03-20

Interdisciplinary teamwork (ITW) is deemed necessary for quality cancer care practices. Nevertheless, variation in ITW intensity among cancer teams is understudied, and quantitative evidence of the effect of different ITW intensities among cancer teams on patients' perceived experience of care is limited. This study aims to compare patient-reported experience measures (PREMs) of cancer outpatients followed by teams characterized by high vs. low ITW intensity. The study is designed as an ex post facto quasi-experimental study. Participants (n = 1379) were recruited in nine outpatient oncology clinics characterized by different ITW intensities. ITW intensities were evaluated using the characteristics of structure (team composition and size) and process (interactions among team members), as per West's seminal work on team effectiveness. ITW intensity was dichotomized (high vs. low ITW intensity). PREMs were classified and measured using validated scales corresponding to six dimensions: Prompt access to care, Person-centred response, Quality of patient-professional communication, Quality of the care environment, Continuity of care, and Results of care. Dichotomous variables were created for each dimension (positive vs. less positive experience). Multiple logistic regression analyses were performed to assess the association between ITW intensities and the six PREMs dimensions, while controlling for patient and organizational characteristics. PROC GENMOD was used to fit logistic models for categorical variables. Outpatients treated by teams characterized by high ITW intensity reported almost four times more positive perceptions of Prompt access to care compared to patients treated by low ITW intensity teams (OR = 3.99; CI = 1.89-8.41). High ITW intensity also positively affected patients' perceptions of Quality of patient-professional communication (OR = 2.37; CI = 1.25-4.51), Person-centred response (OR = 2.11; CI = 1.05-4.24], and Continuity of care (OR = 2.18; CI = 1.07-4.45). No significant association was found between ITW intensity and perceived Results of care (OR = 1.31; CI = 0.68-2.52) or Quality of the care environment (OR = 0.66; CI = 0.31-1.39). This study provides empirical evidence, from the patient's perspective, that ITW intensity affects some critical aspects of patient-reported quality of care. Future research will allow explaining how and why ITW structure and processes may contribute to positive cancer care experiences.

Neonatal intensive care: satisfaction measured from a parent's perspective.

PubMed

Conner, J M; Nelson, E C

1999-01-01

Health care systems today are complex, technically proficient, competitive, and market-driven. One outcome of this environment is the recent phenomenon in the health care field of "consumerism." Strong emphasis is placed on customer service, with organized efforts to understand, measure, and meet the needs of customers served. The purpose of this article is to describe the current understanding and measurement of parent needs and expectations with neonatal intensive care services from the time the expectant parents enter the health care system for the birth through the discharge process and follow-up care. Through literature review, 11 dimensions of care were identified as important to parents whose infants received neonatal intensive care: assurance, caring, communication, consistent information, education, environment, follow-up care, pain management, participation, proximity, and support. Five parent satisfaction questionnaires-the Parent Feedback Questionnaire, Neonatal Index of Parent Satisfaction, Inpatient Parent Satisfaction-Children's Hospital Minneapolis, Picker Institute-Inpatient Neonatal Intensive Care Unit Survey, and the Neonatal Intensive Care Unit-Parent Satisfaction Form-are critically reviewed for their ability to measure parent satisfaction within the framework of the neonatal care delivery process. An immense gap was found in our understanding about what matters most and when to parents going through the neonatal intensive care experience. Additional research is required to develop comprehensive parent satisfaction surveys that measure parent perceptions of neonatal care within the framework of the care delivery process.

Cooccurrence of Post-Intensive Care Syndrome Problems Among 406 Survivors of Critical Illness.

PubMed

Marra, Annachiara; Pandharipande, Pratik P; Girard, Timothy D; Patel, Mayur B; Hughes, Christopher G; Jackson, James C; Thompson, Jennifer L; Chandrasekhar, Rameela; Ely, Eugene Wesley; Brummel, Nathan E

2018-05-21

To describe the frequency of cooccurring newly acquired cognitive impairment, disability in activities of daily livings, and depression among survivors of a critical illness and to evaluate predictors of being free of post-intensive care syndrome problems. Prospective cohort study. Medical and surgical ICUs from five U.S. centers. Patients with respiratory failure or shock, excluding those with preexisting cognitive impairment or disability in activities of daily livings. None. At 3 and 12 months after hospital discharge, we assessed patients for cognitive impairment, disability, and depression. We categorized patients into eight groups reflecting combinations of cognitive, disability, and mental health problems. Using multivariable logistic regression, we modeled the association between age, education, frailty, durations of mechanical ventilation, delirium, and severe sepsis with the odds of being post-intensive care syndrome free. We analyzed 406 patients with a median age of 61 years and an Acute Physiology and Chronic Health Evaluation II of 23. At 3 and 12 months, one or more post-intensive care syndrome problems were present in 64% and 56%, respectively. Nevertheless, cooccurring post-intensive care syndrome problems (i.e., in two or more domains) were present in 25% at 3 months and 21% at 12 months. Post-intensive care syndrome problems in all three domains were present in only 6% at 3 months and 4% at 12 months. More years of education was associated with greater odds of being post-intensive care syndrome free (p < 0.001 at 3 and 12 mo). More severe frailty was associated with lower odds of being post-intensive care syndrome free (p = 0.005 at 3 mo and p = 0.048 at 12 mo). In this multicenter cohort study, one or more post-intensive care syndrome problems were present in the majority of survivors, but cooccurring problems were present in only one out of four. Education was protective from post-intensive care syndrome problems and frailty predictive of the development of post-intensive care syndrome problems. Future studies are needed to understand better the heterogeneous subtypes of post-intensive care syndrome and to identify modifiable risk factors.

A Comparison of State Advance Directive Documents

ERIC Educational Resources Information Center

Gunter-Hunt, Gail; Mahoney, Jane E.; Sieger, Carol E.

2002-01-01

Purpose: Advance directive (AD) documents are based on state-specific statutes and vary in terms of content. These differences can create confusion and inconsistencies resulting in a possible failure to honor the health care wishes of people who execute health care documents for one state and receive health care in another state. The purpose of…

Tracheotomy in the intensive care unit: Guidelines from a French expert panel: The French Intensive Care Society and the French Society of Anaesthesia and Intensive Care Medicine.

PubMed

Trouillet, Jean-Louis; Collange, Olivier; Belafia, Fouad; Blot, François; Capellier, Gilles; Cesareo, Eric; Constantin, Jean-Michel; Demoule, Alexandre; Diehl, Jean-Luc; Guinot, Pierre-Grégoire; Jegoux, Franck; L'Her, Erwan; Luyt, Charles-Edouard; Mahjoub, Yazine; Mayaux, Julien; Quintard, Hervé; Ravat, François; Vergez, Sébastien; Amour, Julien; Guillot, Max

2018-06-01

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the grading of recommendations assessment, development and evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1±) and 6 a low level of proof (Grade 2±). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced. Copyright © 2018 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.

Medical emergency response in a sub-acute hospital: improving the model of care for deteriorating patients.

PubMed

Visser, Philip; Dwyer, Alison; Moran, Juli; Britton, Mary; Heland, Melodie; Ciavarella, Filomena; Schutte, Sandy; Jones, Daryl

2014-05-01

To assess the frequency, characteristics and outcomes of medical emergency response (MER) calls in a sub-acute hospital setting. The present study was a retrospective observational study in a sub-acute hospital providing aged care, palliative care, rehabilitation, veteran's mental health and elective surgical services. We assessed annual MER call numbers between 2005 and 2011 in the context of contemporaneous changes to hospital services. We also assessed MER calls over a 12-month period in detail using standardised case report forms and the scanned medical record. There were 2285 multiday admissions in the study period where 141 MER calls were triggered in 132 patients (61.7 calls per 1000 admissions). The median patient age was 83.0 years, and 55.3% of patients were men. Most calls occurred on weekdays and during the daytime, and were triggered by altered conscious state, low oxygen saturations and hypotension. Documentation of escalation of care before the MER call was not present in 99 of 141 (70.2%) calls. Following the call, in 70 of 141 (49.6%) cases, the patient was transferred to the acute campus, where 52 (74.2%) and 14 (20%) patients required ward and intensive care level treatment, respectively. Thirty-seven of 132 (28%) patients died. A palliative care physician adjudicated that most of these patients who died (24/37; 64.9%) were appropriate for a call, but that 19 (51.4%) should have received palliation at the time of the call. Compared with survivors, patients who died after the MER call were more likely originally admitted from supported accommodation. MER calls in our sub-acute hospital occurred in elderly patients and are associated with an in-hospital mortality of 28%. A small proportion of patients required intensive care level treatment. There is a need to improve processes involving escalation of care before MER call activation and to revise advance care directives. What is known about this topic? Rapid response team (RRT) activation has been well described in the acute hospital setting. Although the impact on survival benefit to patients remains controversial, it has been widely adopted as a model of care to respond to deteriorating ward patients. This is particularly relevant in Australia at present with the implementation of the new National Safety and Quality Health Service Standards. What does this paper add? There have not been any previous papers published on rapid response systems in a sub-acute hospital. This paper describes some of the changes and challenges associated with increasing RRT activations in a sub-acute health care facility. What are the implications for practitioners? For clinicians in a sub-acute setting, the study reinforces the importance of pre-emptively documenting and communicating advance care directives. In addition, it is important to identify patients with reversible pathology likely to benefit from transfer and acute care, and to avoid the transfer of those who will not and, instead, provide appropriate palliation. For practitioners involved in models of care for deteriorating patients, the study provides information on where problems occurred in our system and the strategies used to address these issues.

Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference.

PubMed

Axelrod, David M; Alten, Jeffrey A; Berger, John T; Hall, Mark W; Thiagarajan, Ravi; Bronicki, Ronald A

2015-10-01

Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field. © The Author(s) 2015.

Effect of a Brief Seated Massage on Nursing Student Attitudes Toward Touch for Comfort Care

PubMed Central

Yearwood, Edilma L.; Friedmann, Erika

2014-01-01

Background: While massage has been removed from nursing curricula, studies have reported massage as safe and effective for stress reduction, relaxation, pain relief, fatigue, and quality of life. Objective: To compare the efficacy of two intensities of touch administered during two seated massages on the attitudes of nursing students toward touch for their self-care and patient care. Participants: Nursing students who volunteered gave institutional review board–approved written informed consent to undergo massage by a licensed massage therapist. Settings/location: A private room adjacent to the nursing lab in a school of nursing. Intervention: Brief seated massages of differing intensities. Each participant received low-intensity and high-intensity touch in a two-block, randomized order, within-subjects design. Linear mixed models nested within subject and random intercept analyses were used to test hypotheses in this two-treatment, two-sequence, two-period crossover design. Outcome measures: Health questionnaires/visual analogue scales pertaining to physical/affective/and attitudinal status were completed before and after each massage. Results: Twenty-nine participants (93% female, 83% single) completed the study. Before massage, the optimal intensity of touch anticipated for self-comfort was 6.6 (0=no pressure;10=most intense pressure imaginable). The mean touch intensities were 6.7 for high-intensity massage and 0.5 for low-intensity (p<0.001). The overall percentage differences (feeling better or worse) following massage were as follows: low intensity, 37.5% better; high intensity, 62.7% better (p<0.001). Significantly more improvement was reported for energy, pain, stress, and feeling physically uptight after high-intensity compared with low-intensity (p<0.03). Participants were more likely to both receive touch for self-care and provide touch for patient care after experiencing high- versus low-intensity massage (p<0.01). Conclusions: High-intensity seated massage was more efficacious than low-intensity massage and positively influenced nursing student attitudes toward the inclusion of massage in self-care/patient care. The role of touch for self-care/patient care in the nursing curricula merits reconsideration. PMID:25140587

Transition from an open-plan to a two-cot neonatal intensive care unit: a participatory action research approach.

PubMed

Broom, Margaret; Gardner, Anne; Kecskes, Zsuzsoka; Kildea, Sue

2017-07-01

To facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. In 2012, an Australian regional neonatal intensive care unit transitioned from an open-plan to a two-cot neonatal intensive care unit design. Research has reported single- and small-room neonatal intensive care unit design may negatively impact on the distances nurses walk, reducing the time they spend providing direct neonatal care. Studies have also reported nurses feel isolated and need additional support and education in such neonatal intensive care units. Staff highlighted their concerns regarding the impact of the new design on workflow and clinical practice. A participatory action research approach. A participatory action group titled the Change and Networking Group collaborated with staff over a four-year period (2009-2013) to facilitate the transition. The Change and Networking Group used a collaborative, cyclical process of planning, gathering data, taking action and reviewing the results to plan the next action. Data sources included meeting and workshop minutes, newsletters, feedback boards, subgroup reports and a staff satisfaction survey. The study findings include a description of (1) how the participatory action research cycles were used by the Change and Networking Group: providing examples of projects and strategies undertaken; and (2) evaluations of participatory action research methodology and Group by neonatal intensive care unit staff and Change and Networking members. This study has described the benefits of using participatory action research to facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. Participatory action research methodology enabled the inclusion of staff to find solutions to design and clinical practice questions. Future research is required to assess the long-term effect of neonatal intensive care unit design on staff workload, maintaining and supporting a skilled workforce as well as the impact of a new neonatal intensive care unit design on the neonatal intensive care unit culture. A supportive work environment for staff is critical in providing high-quality health care. © 2016 John Wiley & Sons Ltd.

Time Spent on Dedicated Patient Care and Documentation Tasks Before and After the Introduction of a Structured and Standardized Electronic Health Record.

PubMed

Joukes, Erik; Abu-Hanna, Ameen; Cornet, Ronald; de Keizer, Nicolette F

2018-01-01

Physicians spend around 35% of their time documenting patient data. They are concerned that adopting a structured and standardized electronic health record (EHR) will lead to more time documenting and less time for patient care, especially during consultations. This study measures the effect of the introduction of a structured and standardized EHR on documentation time and time for dedicated patient care during outpatient consultations. We measured physicians' time spent on four task categories during outpatient consultations: documentation, patient care, peer communication, and other activities. Physicians covered various specialties from two university hospitals that jointly implemented a structured and standardized EHR. Preimplementation, one hospital used a legacy-EHR, and one primarily paper-based records. The same physicians were observed 2 to 6 months before and 6 to 8 months after implementation.We analyzed consultation duration, and percentage of time spent on each task category. Differences in time distribution before and after implementation were tested using multilevel linear regression. We observed 24 physicians (162 hours, 439 consultations). We found no significant difference in consultation duration or number of consultations per hour. In the legacy-EHR center, we found the implementation associated with a significant decrease in time spent on dedicated patient care (-8.5%). In contrast, in the previously paper-based center, we found a significant increase in dedicated time spent on documentation (8.3%) and decrease in time on combined patient care and documentation (-4.6%). The effect on dedicated documentation time significantly differed between centers. Implementation of a structured and standardized EHR was associated with 8.5% decrease in time for dedicated patient care during consultations in one center and 8.3% increase in dedicated documentation time in another center. These results are in line with physicians' concerns that the introduction of a structured and standardized EHR might lead to more documentation burden and less time for dedicated patient care. Schattauer GmbH Stuttgart.

[Quality management in intensive care medicine].

PubMed

Martin, J; Braun, J-P

2014-02-01

Treatment of critical ill patients in the intensive care unit is tantamount to well-designed risk or quality management. Several tools of quality management and quality assurance have been developed in intensive care medicine. In addition to external quality assurance by benchmarking with regard to the intensive care medicine, peer review procedures have been established for external quality assurance in recent years. In the process of peer review of an intensive care unit (ICU), external physicians and nurses visit the ICU, evaluate on-site proceedings, and discuss with the managing team of the ICU possibilities for optimization. Furthermore, internal quality management in the ICU is possible based on the 10 quality indicators of the German Interdisciplinary Society for Intensive Care Medicine (DIVI, "Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin"). Thereby every ICU has numerous possibilities to improve their quality management system.

[Quality management in intensive care medicine].

PubMed

Martin, J; Braun, J-P

2013-09-01

Treatment of critical ill patients in the intensive care unit is tantamount to well-designed risk or quality management. Several tools of quality management and quality assurance have been developed in intensive care medicine. In addition to extern quality assurance by benchmarking with regard to the intensive care medicine, peer review procedures have been established for external quality assurance in recent years. In the process of peer review of an intensive care unit (ICU), external physicians and nurses visit the ICU, evaluate on-site proceedings, and discuss with the managing team of the ICU possibilities for optimization. Furthermore, internal quality management in the ICU is possible based on the 10 quality indicators of the German Interdisciplinary Society for Intensive Care Medicine (DIVI, "Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin"). Thereby every ICU has numerous possibilities to improve their quality management system.

Acute renal failure requiring renal replacement therapy in the intensive care unit: impact on prognostic assessment for shared decision making.

PubMed

Johnson, Robert F; Gustin, Jillian

2011-07-01

A 69-year-old female was receiving renal replacement therapy (RRT) for acute renal failure (ARF) in an intensive care unit (ICU). Consultation was requested from the palliative medicine service to facilitate a shared decision-making process regarding goals of care. Clinician responsibility in shared decision making includes the formulation and expression of a prognostic assessment providing the necessary perspective for a spokesperson to match patient values with treatment options. For this patient, ARF requiring RRT in the ICU was used as a focal point for preparing a prognostic assessment. A prognostic assessment should include the outcomes of most importance to a discussion of goals of care: mortality risk and survivor functional status, in this case including renal recovery. A systematic review of the literature was conducted to document published data regarding these outcomes for adult patients receiving RRT for ARF in the ICU. Forty-one studies met the inclusion criteria. The combined mean values for short-term mortality, long-term mortality, renal-function recovery of short-term survivors, and renal-function recovery of long-term survivors were 51.7%, 68.6%, 82.0%, and 88.4%, respectively. This case example illustrates a process for formulating and expressing a prognostic assessment for an ICU patient requiring RRT for ARF. Data from the literature review provide baseline information that requires adjustment to reflect specific patient circumstances. The nature of the acute primary process, comorbidities, and severity of illness are key modifiers. Finally, the prognostic assessment is expressed during a family meeting using recommended principles of communication.

Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario.

PubMed

Mehta, Yatin; Sunavala, J D; Zirpe, Kapil; Tyagi, Niraj; Garg, Sunil; Sinha, Saswati; Shankar, Bhuvaneshwari; Chakravarti, Sanghamitra; Sivakumar, M N; Sahu, Sambit; Rangappa, Pradeep; Banerjee, Tanmay; Joshi, Anshu; Kadhe, Ganesh

2018-04-01

Intensive-care practices and settings may differ for India in comparison to other countries. While international guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to Indian settings. Advisory board meetings were arranged to develop the practice guidelines specific to Indian context, for the use of EN in critically ill patients and to overcome challenges in this field. Various existing guidelines, meta-analyses, randomized controlled trials, controlled trials, and review articles were reviewed for their contextual relevance and strength. A systematic grading of practice guidelines by advisory board was done based on strength of the supporting evidence. Wherever Indian studies were not available, references were taken from the international guidelines. Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding EN versus parenteral nutrition; nutrition screening and assessment; nutrition in hemodynamically unstable; route of nutrition; tube feeding and challenges; tolerance; optimum calorie-protein requirements; selection of appropriate enteral feeding formula; micronutrients and immune-nutrients; standard nutrition in hepatic, renal, and respiratory diseases and documentation of nutrition practices. This paper summarizes the optimum nutrition practices for critically ill patients. The possible solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance in critical care settings regarding appropriate critical-care nutrition practices and to set up Intensive Care Unit nutrition protocols.

Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario

PubMed Central

Mehta, Yatin; Sunavala, J. D.; Zirpe, Kapil; Tyagi, Niraj; Garg, Sunil; Sinha, Saswati; Shankar, Bhuvaneshwari; Chakravarti, Sanghamitra; Sivakumar, M. N.; Sahu, Sambit; Rangappa, Pradeep; Banerjee, Tanmay; Joshi, Anshu; Kadhe, Ganesh

2018-01-01

Background and Aim: Intensive-care practices and settings may differ for India in comparison to other countries. While international guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to Indian settings. Advisory board meetings were arranged to develop the practice guidelines specific to Indian context, for the use of EN in critically ill patients and to overcome challenges in this field. Methods: Various existing guidelines, meta-analyses, randomized controlled trials, controlled trials, and review articles were reviewed for their contextual relevance and strength. A systematic grading of practice guidelines by advisory board was done based on strength of the supporting evidence. Wherever Indian studies were not available, references were taken from the international guidelines. Results: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding EN versus parenteral nutrition; nutrition screening and assessment; nutrition in hemodynamically unstable; route of nutrition; tube feeding and challenges; tolerance; optimum calorie-protein requirements; selection of appropriate enteral feeding formula; micronutrients and immune-nutrients; standard nutrition in hepatic, renal, and respiratory diseases and documentation of nutrition practices. Conclusion: This paper summarizes the optimum nutrition practices for critically ill patients. The possible solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance in critical care settings regarding appropriate critical-care nutrition practices and to set up Intensive Care Unit nutrition protocols. PMID:29743765

Unplanned extubations in an intensive care unit: Findings from a critical incident technique.

PubMed

Danielis, Matteo; Chiaruttini, Simona; Palese, Alvisa

2018-05-15

Patients on mechanical ventilation are at risk of experiencing a potentially life-threatening unplanned extubation in the intensive care unit, which can lead to arrhythmias, bronchial aspiration, difficulty in reintubation or even sudden cardiac arrest. Although incidence and outcomes of the phenomenon have been documented in several quantitative studies, no studies have investigated the antecedents as experienced by critical care nurses. To gain a greater understanding of the antecedents of unplanned extubations. A qualitative study design involving the critical-incident technique. A total of 10 registered nurses who reported one or more episodes of unplanned extubations were involved in an in-depth interview. According to the nurses' experience, episodes of unplanned extubations are determined by predisposing, precipitating and mediating factors. The predisposing factors have been recognised in the (a) weaning programme (expected/unexpected decreased sedation) and in the (b) patient factors (increased needs due to discomfort, restlessness and desire to communicate). The precipitating factors have been divided into (a) organisational (failures in multi-professional communication), (b) environmental (excessive environmental chaos and barriers preventing direct surveillance) and (c) nursing care factors (ensuring privacy by creating barriers, avoiding disturbing other patients and poor nurse-to-patient ratio). Among the mediating factors, which are affected by the precipitating factors, decreased surveillance and mechanical restraints' use have been identified. Identifying risk factors of unplanned extubation, specifically those that are modifiable, such as increasing interprofessional communication, reducing excessive environment chaos, implementing strategies aimed at overcoming barriers threatening direct surveillance and ensuring appropriate nurse-to-patient ratio, can prevent the occurrence of these events. Copyright © 2018 Elsevier Ltd. All rights reserved.

The effect of physician staffing model on patient outcomes in a medical progressive care unit.

PubMed

Yoo, E J; Damaghi, N; Shakespeare, W G; Sherman, M S

2016-04-01

Although evidence supports the impact of intensivist physician staffing in improving intensive care unit (ICU) outcomes, the optimal coverage for progressive care units (PCU) is unknown. We sought to determine how physician staffing models influence outcomes for intermediate care patients. We conducted a retrospective observational comparison of patients admitted to the medical PCU of an academic hospital during 12-month periods of high-intensity and low-intensity staffing. A total of 318 PCU patients were eligible for inclusion (143 high-intensity and 175 low-intensity). We found that low-intensity patients were more often stepped up from the emergency department and floor, whereas high-intensity patients were ICU transfers (61% vs 42%, P = .001). However, Mortality Probability Model scoring was similar between the 2 groups. In adjusted analysis, there was no association between intensity of staffing and hospital mortality (odds ratio, 0.84; 95% confidence interval, 0.36-1.99; P = .69) or PCU mortality (odds ratio, 0.96; 95% confidence interval, 0.38-2.45; P = .69). There was also no difference in subsequent ICU admission rates or in PCU length of stay. We found no evidence that high-intensity intensivist physician staffing improves outcomes for intermediate care patients. In a strained critical care system, our study raises questions about the role of the intensivist in the graded care options between intensive and conventional ward care. Copyright © 2015 Elsevier Inc. All rights reserved.

Improving the Quality of Electronic Documentation in Critical Care Nursing

ERIC Educational Resources Information Center

Stevens, Brent

2017-01-01

Electronic nursing documentation systems can facilitate complete, accurate, timely documentation practices, but without effective policies and procedures in place, a gap in practice exists and quality of care may be impacted. This systematic review of literature examined current evidence regarding electronic nursing documentation quality. General…

Advance Care Planning in palliative care: a qualitative investigation into the perspective of Paediatric Intensive Care Unit staff.

PubMed

Mitchell, Sarah; Dale, Jeremy

2015-04-01

The majority of children and young people who die in the United Kingdom have pre-existing life-limiting illness. Currently, most such deaths occur in hospital, most frequently within the intensive care environment. To explore the experiences of senior medical and nursing staff regarding the challenges associated with Advance Care Planning in relation to children and young people with life-limiting illnesses in the Paediatric Intensive Care Unit environment and opportunities for improvement. Qualitative one-to-one, semi-structured interviews were conducted with Paediatric Intensive Care Unit consultants and senior nurses, to gain rich, contextual data. Thematic content analysis was carried out. UK tertiary referral centre Paediatric Intensive Care Unit. Eight Paediatric Intensive Care Unit consultants and six senior nurses participated. Four main themes emerged: recognition of an illness as 'life-limiting'; Advance Care Planning as a multi-disciplinary, structured process; the value of Advance Care Planning and adverse consequences of inadequate Advance Care Planning. Potential benefits of Advance Care Planning include providing the opportunity to make decisions regarding end-of-life care in a timely fashion and in partnership with patients, where possible, and their families. Barriers to the process include the recognition of the life-limiting nature of an illness and gaining consensus of medical opinion. Organisational improvements towards earlier recognition of life-limiting illness and subsequent Advance Care Planning were recommended, including education and training, as well as the need for wider societal debate. Advance Care Planning for children and young people with life-limiting conditions has the potential to improve care for patients and their families, providing the opportunity to make decisions based on clear information at an appropriate time, and avoid potentially harmful intensive clinical interventions at the end of life. © The Author(s) 2015.

The Role of Documentation Quality in Anesthesia-Related Closed Claims: A Descriptive Qualitative Study.

PubMed

Wilbanks, Bryan A; Geisz-Everson, Marjorie; Boust, Rebecca R

2016-09-01

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

Improving care by understanding the way we work: human factors and behavioural science in the context of intensive care

PubMed Central

Sevdalis, Nick; Brett, Stephen J

2009-01-01

Effectiveness and efficiency of care of the critically ill patient are subject to a number of systemic influences, including skills of individual physicians/nurses (technical and non-technical), team-working in the intensive care unit (ICU), and the ICU environment. We first discuss the paper of Fackler and colleagues as a contribution to the systems approach to clinical performance in the context of intensive care. We then highlight features of care delivery that are unique to intensive care and discuss the need for better understanding of human and non-human elements of the system of care of the critically ill patient as a driver for improvement of care delivery. PMID:19439048

Moral decision making in neonatal intensive care.

PubMed

Chally, P S

1992-01-01

To gain information about the perspective that neonatal intensive-care unit nurses use to make moral decisions. Descriptive. Neonatal intensive-care unit of a large teaching hospital in the midwestern United States. Convenience sample of 26 female nurses working in a neonatal intensive-care unit. Audiotaped, semistructured interviews and demographic questionnaires. The results indicated that most (65%) of the nurses used the care perspective to make moral decisions. A small number (12%) used the justice perspective, and the remaining nurses (23%) used a combined care and justice perspective. Both the care and justice perspectives were found to be important for understanding how nurses make moral decisions.

Rethinking the intensive care environment: considering nature in nursing practice.

PubMed

Minton, Claire; Batten, Lesley

2016-01-01

With consideration of an environmental concept, this paper explores evidence related to the negative impacts of the intensive care unit environment on patient outcomes and explores the potential counteracting benefits of 'nature-based' nursing interventions as a way to improve care outcomes. The impact of the environment in which a patient is nursed has long been recognised as one determinant in patient outcomes. Whilst the contemporary intensive care unit environment contains many features that support the provision of the intensive therapies the patient requires, it can also be detrimental, especially for long-stay patients. This narrative review considers theoretical and evidence-based literature that supports the adoption of nature-based nursing interventions in intensive care units. Research and theoretical literature from a diverse range of disciplines including nursing, medicine, psychology, architecture and environmental science were considered in relation to patient outcomes and intensive care nursing practice. There are many nature-based interventions that intensive care unit nurses can implement into their nursing practice to counteract environmental stressors. These interventions can also improve the environment for patients' families and nurses. Intensive care unit nurses must actively consider and manage the environment in which nursing occurs to facilitate the best patient outcomes. © 2015 John Wiley & Sons Ltd.

Gradually Disengaging: Parent-Health care Provider Relationships After a Child's Death in the Pediatric Intensive Care Unit.

PubMed

Butler, Ashleigh E; Hall, Helen; Copnell, Beverley

2018-06-01

When a child dies in the intensive care unit, many bereaved parents want relationships with their child's health care staff to continue in the form of follow-up care. However, the nature of these relationships and how they change across the parents' bereavement journey is currently unknown. This article explores early and ongoing relationships between parents and health care staff when a child dies in intensive care. Constructivist grounded theory methods were used to recruit 26 bereaved parents from four Australian pediatric intensive care units into the study. Data were collected via audio-recorded, semistructured interviews and analyzed using the constant comparative methods and theoretical memoing. Findings show that these relationships focus on Gradually disengaging, commonly moving through three phases after the child dies: Saying goodbye, Going home, and Seeking supports. These findings provide guidance to health care staff on what families need as they leave the intensive care unit and move through bereavement.

The organisation of critical care for burn patients in the UK: epidemiology and comparison of mortality prediction models.

PubMed

Toft-Petersen, A P; Ferrando-Vivas, P; Harrison, D A; Dunn, K; Rowan, K M

2018-05-15

In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn-specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn-specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7-32 [0-98])% vs. 8 (1-18 [0-100])%, respectively) but in-hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn-specific models for patients managed on both specialist burn and general intensive care units. © 2018 The Association of Anaesthetists of Great Britain and Ireland.

Defining the Medical Intensive Care Unit in the Words of Patients and Their Family Members: A Freelisting Analysis.

PubMed

Auriemma, Catherine L; Lyon, Sarah M; Strelec, Lauren E; Kent, Saida; Barg, Frances K; Halpern, Scott D

2015-07-01

No validated conceptual framework exists for understanding the outcomes of patient- and family-centered care in critical care. To explore the meaning of intensive care unit among patients and their families by using freelisting. The phrase intensive care unit was used to prompt freelisting among intensive care unit patients and patients' family members. Freelisting is an anthropological technique in which individuals define a domain by listing all words that come to mind in response to a topic. Salience scores, derived from the frequency with which a word was mentioned, the order in which it was mentioned, and the length of each list, were calculated and analyzed. Among the 45 participants, many words were salient to both patients and patients' family members. Words salient solely for patients included consciousness, getting better, noisy, and personal care. Words salient solely for family members included sadness, busy, professional, and hope. The words suffering, busy, and team were salient solely for family members of patients who lived, whereas sadness, professionals, and hope were salient solely for family members of patients who died. The words caring and death were salient for both groups. Intensive care unit patients and their families define intensive care unit by using words to describe sickness, caring, medical staff, emotional states, and physical qualities of the unit. The results validate the importance of these topics among patients and their families in the intensive care unit and illustrate the usefulness of freelisting in critical care research. ©2015 American Association of Critical-Care Nurses.

36 CFR 1254.36 - What care must I take when handling documents?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 36 Parks, Forests, and Public Property 3 2010-07-01 2010-07-01 false What care must I take when... Room Rules Rules Relating to Using Original Documents § 1254.36 What care must I take when handling... must not use paper clips, rubber bands, self-stick notes or similar devices to identify documents. (e...

Team working in intensive care: current evidence and future endeavors.

PubMed

Richardson, Joanne; West, Michael A; Cuthbertson, Brian H

2010-12-01

It has recently been argued that the future of intensive care medicine will rely on high quality management and teamwork. Therefore, this review takes an organizational psychology perspective to examine the most recent research on the relationship between teamwork, care processes, and patient outcomes in intensive care. Interdisciplinary communication within a team is crucial for the development of negotiated shared treatment goals and short-team patient outcomes. Interventions for maximizing team communication have received substantial interest in recent literature. Intensive care coordination is not a linear process, and intensive care teams often fail to discuss how to implement goals, trigger and align activities, or reflect on their performance. Despite a move toward interdisciplinary team working, clinical decision-making is still problematic and continues to be perceived as a top-down and authoritative process. The topic of team leadership in intensive care is underexplored and requires further research. Based on findings from the most recent research evidence in medicine and management, four principles are identified for improving the effectiveness of team working in intensive care: engender professional efficacy, create stable teams and leaders, develop trust and participative safety, and enable frequent team reflexivity.

Physician Reimbursement for Critical Care Services Integrating Palliative Care for Patients Who Are Critically Ill

PubMed Central

Nelson, Judith E.; Weissman, David E.; Hays, Ross M.; Mosenthal, Anne C.; Mulkerin, Colleen; Puntillo, Kathleen A.; Ray, Daniel E.; Bassett, Rick; Boss, Renee D.; Brasel, Karen J.; Campbell, Margaret L.; Cortez, Therese B.; Curtis, J. Randall

2012-01-01

Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes. PMID:22396564

End-of-life care of oncology inpatients: Are we getting it right?

PubMed

Batten, Monique; Nguyen, Bella; Burke, Brandon; Harryanto, Hilman; Mitchell, Imogen; Davis, Alison

2018-06-13

To examine the current patterns of end-of-life care of medical oncology patients dying in an Australian tertiary acute hospital setting in order to determine potential areas for improvement. A retrospective observational study was undertaken of 295 consecutive adult medical oncology inpatients dying between 2010 and 2015. Charts were reviewed for evidence of (1) resuscitation plans, (2) acute interventions in the 48-h period prior to death, (3) palliative care involvement and (4) recognition of the dying patient and comfort care plans. At the time of death, 98% of patients had a resuscitation plan, 71% of which were completed by the medical oncology team. Fifty-nine percent of medical emergency team reviews occurred in patients without a documented resuscitation plan. Within 48 h of death, active interventions were still being given to 64% of patients in the total patient population. Comfort care plans were documented in 86% of patients; however, 62% of these were only documented within 48 h of death and 20% of patients with a documented comfort care plan still received noncomfort measures. There was a high level of documented resuscitation plans, comfort care plans and recognition of dying. However, active interventions were common within 48 h of death, and comfort care plans and recognition of dying often occurred late. These data indicate a gap between documenting a resuscitation plan and providing timely and appropriate end-of-life care. Understanding the gaps in delivering appropriate care provides an opportunity for improving end-of-life care. © 2018 John Wiley & Sons Australia, Ltd.

Prevention of central venous catheter infections: a survey of paediatric ICU nurses' knowledge and practice.

PubMed

Ullman, Amanda J; Long, Debbie A; Rickard, Claire M

2014-02-01

Central venous catheters are important in the management of paediatric intensive care unit patients, but can have serious complications which worsen the patients' health, prolong hospital stays and increase the cost of care. Evidence-based recommendations for preventing catheter-related bloodstream infections are available, but it is unknown how widely these are known or practiced in the paediatric intensive care environment. To assess nursing knowledge of evidence based guidelines to prevent catheter-related bloodstream infections; the extent to which Australia and New Zealand paediatric intensive cares have adopted prevention practices; and to identify the factors that encouraged their adoption and improve nursing knowledge. Cross-sectional surveys using convenience sampling. Tertiary level paediatric intensive care units in Australia and New Zealand. Paediatric intensive care nursing staff and nurse managers. Between 2010 and 2011, the 'Paediatric Intensive Care Nurses' Knowledge of Evidence-Based Catheter-Related Bloodstream Infection Prevention Questionnaire' was distributed to paediatric intensive care nursing staff and the 'Catheter-Related Bloodstream Infection Prevention Practices Survey' was distributed to nurse managers to measure knowledge, practices and culture. The questionnaires were completed by 253 paediatric intensive care nurses (response rate: 34%). The mean total knowledge score was 5.5 (SD=1.4) out of a possible ten, with significant variation of total scores between paediatric intensive care sites (p=0.01). Other demographic characteristics were not significantly associated with variation in total knowledge scores. All nursing managers from Australian and New Zealand paediatric intensive care units participated in the survey (n=8; response rate: 100%). Wide practice variation was reported, with inconsistent adherence to recommendations. Safety culture was not significantly associated with mean knowledge scores per site. This study has identified that there is variation in the infection prevention approach and nurses' knowledge about catheter-related bloodstream infection prevention. The presence of an improved safety culture, years of paediatric intensive care experience and higher qualifications did not influence the nurses' uptake of recommendations, therefore further factors need to be explored in order to improve understanding and implementation of best practice. Copyright © 2014 Elsevier Ltd. All rights reserved.

Computer-based nursing documentation in nursing homes: A feasibility study.

PubMed

Yu, Ping; Qiu, Yiyu; Crookes, Patrick

2006-01-01

The burden of paper-based nursing documentation has led to increasing complaints and decreasing job satisfaction amongst aged-care workers in Australian nursing homes. The automation of nursing documentation has been identified as one of the possible strategies to address this issue. A major obstacle to the introduction of IT solutions, however, has been a prevailing doubt concerning the ability and/or the willingness of aged-care workers to accept such innovation. This research investigates the attitudes of aged-care workers towards adopting IT innovation. Questionnaire survey were conducted in 13 nursing homes around the Illawarra and Sydney regions in Australia. The survey found that an unexpected 89.3% of participants supported the strategy of introducing electronic nursing documentation systems into residential aged-care facilities. 94.3% of them would use such a system depending on circumstances. Despite a shortage of computers in the workplace, which is a major barrier, this research provides strong evidence that care workers in residential aged-care facilities are willing to accept electronic nursing documentation practice and the uptake of information technology in residential aged-care is feasible in Australia.

The association between spiritual well-being and burnout in intensive care unit nurses: A descriptive study.

PubMed

Kim, Hyun Sook; Yeom, Hye-Ah

2018-06-01

To describe the spiritual well-being and burnout of intensive care unit nurses and examine the relationship between these factors. This was a cross-sectional descriptive study. The participants were 318 intensive care unit recruited from three university hospitals in South Korea. The survey questionnaire included demographic information, work-related characteristics and end-of-life care experience, along with the Spiritual Well-Being Scale and Burnout Questionnaire. The data were analysed using descriptive statistics, t-tests, ANOVA with Scheffé test and a multiple regression analysis. The burnout level among intensive care unit nurses was 3.15 out of 5. A higher level of burnout was significantly associated with younger age, lower education level, single marital status, having no religion, less work experience and previous end-of-life care experience. Higher levels of spiritual well-being were associated with lower levels of burnout, even after controlling for the general characteristics in the regression model. Intensive care unit nurses experience a high level of burnout in general. Increased spiritual well-being might reduce burnout among intensive care unit nurses. Younger and less experienced nurses should receive more attention as a vulnerable group with lower spirituality and greater burnout in intensive care unit settings. Copyright © 2017 Elsevier Ltd. All rights reserved.

PPO and HMO performance factors: insurance company evaluation criteria.

PubMed

Rodin, B E

1993-01-01

A venture into managed care should be done only following the proper amount of due diligence. The goal should be to select the most effective managed care organization with the flexibility to meet long-term needs and the mission to work on an ongoing basis to improve service and managed care performance. Unfortunately, all too often purchasers do not demand critical information from managed care service providers. As a result, poor quality organizations have prospered and delivered less than satisfactory results. In fact, it is not unusual that savings from discounts are more than offset by increased use of health care services because of poor utilization management. It is important to be aware that use of the appropriate selection methods and monitoring performance on an ongoing basis are best done by dedicated professionals. They are also resource intensive and require a sophisticated systems capability. Since resources and systems involve significant investment, the most appropriate course for purchasers is to play the role of educated consumers. Detailed documentation should be demanded from all potential service providers to ensure that due diligence and ongoing management are in fact performed. The health care management staff at ITT Hartford is often told by managed care vendors that few other purchasers perform thorough review. It is imperative that managed care be scrutinized at least as closely as any important business venture.

Brain damage treated with non proven intensive training 2003-2011: a Norwegian cost analysis.

PubMed

Norum, Jan; Ramsvik, Arnborg; Tjeldnes, Knut

2012-10-10

There has been an increased request for intensive training and rehabilitation of patients with brain damage in Norway. These programs are demanding with regard to personnel, travelling, time and economic resources. We aimed to indicate cost and gain to make these programs cost-effective. A retrospective study included all patients referred to the Northern Norway Regional Health Authority (NNRHA) trust during the nine years period 2003-2011. All referrals to the NNRHA trust for the economic coverage of foreign based rehabilitation or habilitation programs (The Advanced Bio-Mechanical Rehabilitation (ABR), Institutes of Achievement of Human Potential program (IAHP) (Doman Method), Family Hope Center (FHC) program and the Kozijavkin Method) were included. 17 patients were detected and 15 fulfilled the inclusion criteria for funding. Median age was 8 years (1-31 years). Cost from the specialist health care point of view was calculated. A cut-off limit of €57,000/quality adjusted life year (QALY) and a 4% discount rate was employed. The undiscounted cost per patient enrolled was calculated €133,210 (discounted €121,348). To make these therapies cost effective, a total of at least 2.13 QALYs (2.34 undiscounted QALYs) must be gained per patient enrolled. Such a gain could not be indicated and we doubt it is achievable. Non-proven intensive training programs for patients with brain damage are costly. As long as their effect has not been documented, health care services should not spend resources on these programs outside clinical trials.

Rates and determinants of informed consent: a case study of an international thromboprophylaxis trial.

PubMed

Smith, Orla M; McDonald, Ellen; Zytaruk, Nicole; Foster, Denise; Matte, Andrea; Clarke, France; Meade, Laurie; O'Callaghan, Nicole; Vallance, Shirley; Galt, Pauline; Rajbhandari, Dorrilyn; Rocha, Marcelo; Mehta, Sangeeta; Ferguson, Niall D; Hall, Richard; Fowler, Robert; Burns, Karen; Qushmaq, Ismael; Ostermann, Marlies; Heels-Ansdell, Diane; Cook, Deborah

2013-02-01

Successful completion of randomized trials depends upon efficiently and ethically screening patients and obtaining informed consent. Awareness of modifiable barriers to obtaining consent may inform ongoing and future trials. The objective of this study is to describe and examine determinants of consent rates in an international heparin thromboprophylaxis trial (Prophylaxis for ThromboEmbolism in Critical Care Trial, clinicaltrials.gov NCT00182143). Throughout the 4-year trial, research personnel approached eligible critically ill patients or their substitute decision makers for informed consent. Whether consent was obtained or declined was documented daily. The trial was conducted in 67 centers in 6 countries. A total of 3764 patients were randomized. The overall consent rate was 82.2% (range, 50%-100%) across participating centers. Consent was obtained from substitute decision makers and patients in 90.1% and 9.9% of cases, respectively. Five factors were independently associated with consent rates. Research coordinators with more experience achieved higher consent rates (odds ratio [OR], 3.43; 95% confidence interval, 2.42-4.86; P < .001 for those with >10 years of experience). Consent rates were higher in smaller intensive care units with less than 15 beds compared with intensive care units with 15 to 20 beds, 21 to 25 beds, and greater than 25 beds (all ORs, <0.5; P < .001) and were higher in centers with more than 1 full-time research staff (OR, 1.95; 95% confidence interval, 1.28-2.99; P < .001). Consent rates were lower in centers affiliated with the Canadian Critical Care Trials Group or the Australian and New Zealand Intensive Care Society Clinical Trials Group compared with other centers (OR, 0.57; 95% confidence interval, 0.42-0.77; P < .001). Finally, consent rates were highest during the pilot trial, lowest during the initiation of the full trial, and increased over years of recruitment (P < .001). Characteristics of study centers, research infrastructure, and experience were important factors associated with successfully procuring informed consent to participate in this thromboprophylaxis trial. Copyright © 2013 Elsevier Inc. All rights reserved.

Tutorial and hands-on demonstration of a fluent interpreter for CARE 3

NASA Technical Reports Server (NTRS)

Martensen, Anna L.; Bavuso, Salvatore J.

1987-01-01

This document updates one originally written as part of a workshop on the CARE 3 capability held at NASA Langley Research Center on February 22 to 24, 1984. Subsequent to the workshop, CARE 3 and its interface program were enhanced and extensive changes to the original document became necessary. This document, like its predecessor, is designed to illustrate the user interface capability and the salient CARE 3 features by describing various examples of reliability models and their solutions through the use of CARE 3.

A new patient registration method for intensive care department management.

PubMed

Van Aken, P; Bossaert, L; Gilot, C; Tielemans, L

1987-01-01

A new method to describe intensive care department performance is presented. The method is a complication of available administrative and medical data, completed with a severity of illness measure (Acute Physiology And Chronic Health Evaluation, APACHE) and the registration of nursing care intensity. The development of this latter patient stratification system (Intensive Care Activity Score, INCAS) is described. The performance of the method is demonstrated by a study of 200 consecutive admissions.

Healthcare professionals' views of smart glasses in intensive care: A qualitative study.

PubMed

Romare, Charlotte; Hass, Ursula; Skär, Lisa

2018-04-01

The aim of this study was to describe healthcare professionals' views of smart glasses before their implementation in an intensive care unit, both regarding quality of use of the glasses and to identify possible intensive care situations where the glasses could be used to increase patient safety. Data were generated through focus group interviews and analysed using thematic content analysis. The findings describe participants' views of smart glasses divided into three categories; Smart glasses to facilitate work at intensive care unit; Quality of use and Utilisation. Participants assumed smart glasses to cause both effect and affect in intensive care. Participants' concern for patients arose recurrently and through their concern intention to work to promote patient safety. Smart glasses are suggested as a complement to existing monitoring and routines and cannot replace human presence in intensive care. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Reorganising the pandemic triage processes to ethically maximise individuals' best interests.

PubMed

Tillyard, Andrew

2010-11-01

To provide a revised definition, process and purpose of triage to maximise the number of patients receiving intensive care during a crisis. Based on the ethical principle of virtue ethics and the underlying goal of providing individual patients with treatment according to their best interests, the methodology of triage is reassessed and revised. The decision making processes regarding treatment decisions during a pandemic are redefined and new methods of intensive care provision recommended as well as recommending the use of a 'ranking' system for patients excluded from intensive care, defining the role of non-intensive care specialists, and applying two types of triage as 'organisational triage' and 'treatment triage' based on the demand for intensive care. Using a different underlying ethical basis upon which to plan for a pandemic crisis could maximise the number of patients receiving intensive care based on individual patients' best interests.

Prevalence and management of back pain in adolescent idiopathic scoliosis patients: A retrospective study

PubMed Central

Théroux, Jean; Le May, Sylvie; Fortin, Carole; Labelle, Hubert

2015-01-01

BACKGROUND: Back pain (BP) has often been associated with adolescent idiopathic scoliosis (AIS), which is a three-dimensional deviation of the vertebral column. In adolescents, chronic pain appears to be a predictor of health care utilization and has a negative impact on physical, psychological and family well-being. In this population, BP tends to be persistent and may be a predictor of BP in adulthood. OBJECTIVE: To document the prevalence and management of BP in AIS patients. METHODS: A retrospective chart review of AIS patients who were referred to Sainte-Justine University Teaching Hospital (Montreal, Quebec) from 2006 to 2011 was conducted. RESULTS: A total of 310 randomly selected charts were reviewed. Nearly one-half of the patients (47.3%) mentioned that they experienced BP, most commonly in the lumbar (19.7%) and thoracic regions (7.7%). The type of BP was documented in only 36% (n=112) of the charts. Pain intensity was specified in only 21% (n=65) of the charts. In approximately 80% (n=248) of the charts, no pain management treatment plan was documented. CONCLUSIONS: The prevalence of BP was moderately high among the present sample of adolescents with AIS. An improved system for documenting BP assessment, type, treatment plan and treatment effectiveness would improve pain management for these patients. PMID:25831076

Interhospital paediatric intensive care transport: a novel transport unit based on a standard ambulance trolley.

PubMed

Vos, Gijs D; Buurman, Wim A; van Waardenburg, Dick A; Visser, Timo P L; Ramsay, Graham; Donckerwolcke, Raymond A M G

2003-09-01

A recent development in providing intensive care for children is that it is more and more centralized in tertiary centres. The centralization of intensive care facilities for children in tertiary centres demands a safe and well-organized transport system. The transfer of critically ill children from a referring general hospital to a tertiary paediatric intensive care centre should be performed by a specially trained and fully equipped transport team. During the transfer of these children continuous intensive care facilities should be provided. The minimal requirements of equipment and materials for transport that allow such care have been determined. The equipment consists of a monitor allowing continuous measurement of vital signs, a defibrillator, tools for airway and ventilatory management, an oxygen source, suction unit, fluid and electrolyte management, medication, resuscitation chart and a communication system. A mobile paediatric intensive care unit was constructed in order to store this equipment, including easily accessible ventilator and materials optimized for close patient observation and ventilator control.

Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences With Cost-Conscious Care.

PubMed

Leep Hunderfund, Andrea N; Dyrbye, Liselotte N; Starr, Stephanie R; Mandrekar, Jay; Naessens, James M; Tilburt, Jon C; George, Paul; Baxley, Elizabeth G; Gonzalo, Jed D; Moriates, Christopher; Goold, Susan D; Carney, Patricia A; Miller, Bonnie M; Grethlein, Sara J; Fancher, Tonya L; Reed, Darcy A

2017-05-01

To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care. Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index. Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001). Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.

Cardiopulmonary resuscitation standards for clinical practice and training in the UK.

PubMed

Gabbott, David; Smith, Gary; Mitchell, Sarah; Colquhoun, Michael; Nolan, Jerry; Soar, Jasmeet; Pitcher, David; Perkins, Gavin; Phillips, Barbara; King, Ben; Spearpoint, Ken

2005-07-01

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post-resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.

Cardiopulmonary resuscitation standards for clinical practice and training in the UK.

PubMed

Gabbott, David; Smith, Gary; Mitchell, Sarah; Colquhoun, Michael; Nolan, Jerry; Soar, Jasmeet; Pitcher, David; Perkins, Gavin; Phillips, Barbara; King, Ben; Spearpoint, Ken

2005-01-01

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.

Participant observation of time allocation, direct patient contact and simultaneous activities in hospital physicians.

PubMed

Weigl, Matthias; Müller, Andreas; Zupanc, Andrea; Angerer, Peter

2009-06-29

Hospital physicians' time is a critical resource in medical care. Two aspects are of interest. First, the time spent in direct patient contact - a key principle of effective medical care. Second, simultaneous task performance ('multitasking') which may contribute to medical error, impaired safety behaviour, and stress. There is a call for instruments to assess these aspects. A preliminary study to gain insight into activity patterns, time allocation and simultaneous activities of hospital physicians was carried out. Therefore an observation instrument for time-motion-studies in hospital settings was developed and tested. 35 participant observations of internists and surgeons of a German municipal 300-bed hospital were conducted. Complete day shifts of hospital physicians on wards, emergency ward, intensive care unit, and operating room were continuously observed. Assessed variables of interest were time allocation, share of direct patient contact, and simultaneous activities. Inter-rater agreement of Kappa = .71 points to good reliability of the instrument. Hospital physicians spent 25.5% of their time at work in direct contact with patients. Most time was allocated to documentation and conversation with colleagues and nursing staff. Physicians performed parallel simultaneous activities for 17-20% of their work time. Communication with patients, documentation, and conversation with colleagues and nursing staff were the most frequently observed simultaneous activities. Applying logit-linear analyses, specific primary activities increase the probability of particular simultaneous activities. Patient-related working time in hospitals is limited. The potential detrimental effects of frequently observed simultaneous activities on performance outcomes need further consideration.

Impact of an aseptic procedure for breaking the integrity of the urinary drainage system on the development of catheter-associated urinary tract infections in the intensive care unit.

PubMed

Powers, Jan

2016-12-01

Catheter associated urinary tract infections (CAUTI) are a common complication in the hospital, especially in intensive care units (ICU). These infections are directly linked to the use of an indwelling urinary catheter. One commonly identified factor related to the development of CAUTI has been thought to be violating the integrity of the closed drainage system. However, a paucity of research exists to support or refute this practice. The primary purpose of this observational study was to assess if there is a relationship between CAUTI incidence and breaking the closed drainage system using an aseptic procedure. A process improvement effort was developed to ensure an aseptic technique was utilised when there was a need to break the integrity of the urinary drainage system. Because this was a new practice and not supported by the Centres for Disease Control (CDC) recommendations, this change in practice was evaluated as an observational study. In an eight month period there were 53 documented breaks in the urinary drainage system. There were 28 total cases of CAUTI overall during this same time period. Only four patients with a system break developed a CAUTI (7.5%). In almost 93% of the patients where aseptic technique was used for breaks in the drainage system, there was no occurrence of CAUTI. A follow-up evaluation was performed after a year of this practice in three adult ICUs. During this three month evaluation period, there were 47 documented cases of breaking this system using aseptic technique. Of the patients who had a documented break in their drainage system, none developed subsequent CAUTIs. One commonly identified factor related to the development of CAUTI has been thought to be violating the integrity of the closed drainage system. However, a paucity of research exists to support or refute this practice. This observational study found that utilising an aseptic technique to break the integrity system did not result in an associated increase in CAUTI. Copyright © 2016 Elsevier Ltd. All rights reserved.

Are neonatal intensive care resources located according to need? Regional variation in neonatologists, beds, and low birth weight newborns.

PubMed

Goodman, D C; Fisher, E S; Little, G A; Stukel, T A; Chang , C H

2001-08-01

Despite marked growth in neonatal intensive care during the past 30 years, it is not known if neonatologists and beds are preferentially located in regions with greater newborn risk. This study reports the relationship between regional measures of intensive care capacity and low birth weight infants using newly developed market-based regions of neonatal intensive care. Cross-sectional small-area analysis of 246 neonatal intensive care regions (NICRs). 1996 American Medical Association and American Osteopathic Association masterfiles data of clinically active neonatologists; 1999 American Academy of Pediatrics Section on Perinatal Pediatrics survey of directors of neonatal intensive care units in the United States with 100% response rate; 1995 linked birth/death data. The number of total births per neonatologist across NICRs ranged from 390 to 8197 (median: 1722) and the number of total births per intensive care bed ranged from 72 to 1319 (median: 317). The associations between capacity measures and low birth weight rates across NICRs were statistically significant but negligible (R(2): 0.04 for neonatologists; 0.05 for beds). NICRs in the quintile with the greatest neonatologist capacity (average of only 863 births per neonatologist) had very low birth weight (VLBW) rates of 1.5% while those in the quintile of lowest neonatologist capacity (average of 3718 births per neonatologist) had VLBW rates of 1.3%; a similar lack of meaningful difference in VLBW rates was noted across quintiles of intensive care bed capacity. Including midlevel providers and intermediate care beds to the analyses did not alter the findings. Neonatal intensive care capacity is not preferentially located in regions with greater newborn need as measured by low birth weight rates. Whether greater capacity affords benefits to the newborns remains unknown.

Quality of life in long-term survivors of intensive care.

PubMed

Buckley, T A; Cheng, A Y; Gomersall, C D

2001-05-01

Traditionally, outcome from intensive care has focused on mortality. The cost of intensive care and the limited resources devoted to patients who have a poor prognosis also raises questions about the utilisation of such resources. There is increasing pressure for outcome evaluation of intensive care to incorporate assessment of long-term survival and the quality of life in survivors. The principal objectives of this article were to examine current methods of assessing quality of life measures in critically ill patients surviving intensive care and to determine the quality of life of these survivors. Direct and computerised search of published research articles. Measurement of quality of life after intensive care is not common practice. There is a lack of consensus concerning appropriate measuring instruments to be used and how best to interpret results. Despite the availability of general outcome tools and disease specific instruments, there is a paucity of studies in the literature which include assessments of quality of life following intensive care unit (ICU) care. Generic health indices suggest that the quality of life in ICU survivors is acceptable though in certain sub-groups, e.g. adult respiratory distress syndrome and sepsis, quality of life may be moderately impaired. ICU survivors appear to suffer less disability than chronic physical disease patients. Assessment of outcome after intensive care should include health related quality of life measurements. A unifying framework is required to enhance communication between clinicians, administrators and investigators of quality of life research and also to enable more rational and effective decision making at the bedside. Patients who survive intensive care appear to enjoy a reasonable standard of quality of life. While their health status may not be as good, subjectively patients find this acceptable.

Comparative Effectiveness Research and Children With Cerebral Palsy: Identifying a Conceptual Framework and Specifying Measures.

PubMed

Gannotti, Mary E; Law, Mary; Bailes, Amy F; OʼNeil, Margaret E; Williams, Uzma; DiRezze, Briano

2016-01-01

A step toward advancing research about rehabilitation service associated with positive outcomes for children with cerebral palsy is consensus about a conceptual framework and measures. A Delphi process was used to establish consensus among clinicians and researchers in North America. Directors of large pediatric rehabilitation centers, clinicians from large hospitals, and researchers with expertise in outcomes participated (N = 18). Andersen's model of health care utilization framed outcomes: consumer satisfaction, activity, participation, quality of life, and pain. Measures agreed upon included Participation and Environment Measure for Children and Youth, Measure of Processes of Care, PEDI-CAT, KIDSCREEN-10, PROMIS Pediatric Pain Interference Scale, Visual Analog Scale for pain intensity, PROMIS Global Health Short Form, Family Environment Scale, Family Support Scale, and functional classification levels for gross motor, manual ability, and communication. Universal forms for documenting service use are needed. Findings inform clinicians and researchers concerned with outcome assessment.

Nurse education regarding agitated patients and its effects on clinical practice.

PubMed

Ozdemir, Leyla; Karabulut, Erdem

This study identified the impact of an education program on nurses' practices for agitated patients and documented the changes in practice after completion of the training. Eighteen cardiac intensive care nurses were included to the study. Prior to nurses' participation in an education program, a pre-test indicating nurses' current practices for 40 agitated patients was evaluated with the 'Nurse Practice Form'. After the pre-test data collection period was completed, the 2-day training program on caring for agitated patients was conducted. The last step of the study was evaluation of post-test nurses' practices for 40 agitated patients using the 'Nurse Practice Form'. The findings indicated that instead of pre-test nurses' use of physical restraints for controlling agitated patients without a physician order, none of post-test nurses applied them. The training program provided nurses the knowledge and skills needed to evaluate and to manage the causes of agitation.

Beyond winning: mediation, conflict resolution, and non-rational sources of conflict in the ICU

PubMed Central

2012-01-01

A 55-year-old woman with widely metastatic breast cancer was admitted to your intensive care unit (ICU) because of a decreased level of consciousness and respiratory failure. She had documented cerebral and meningeal metastases that were progressing despite chemotherapy and radiotherapy. The admitting physician met with her family and suggested a palliative approach, making them very upset. The family insisted that the team 'do everything' and now they refuse to discuss any change in the plan of treatment. They maintain a constant presence at the bedside, taking notes and questioning everyone who enters the room. They have threatened legal action toward several of the nursing staff, and hospital security has been called twice because of shouting matches between family and staff members. As the physician taking over care for the ICU, you would like to resolve this conflict. PMID:22713247

Beyond winning: mediation, conflict resolution, and non-rational sources of conflict in the ICU.

PubMed

Knickle, Kerry; McNaughton, Nancy; Downar, James

2012-06-19

A 55-year-old woman with widely metastatic breast cancer was admitted to your intensive care unit (ICU) because of a decreased level of consciousness and respiratory failure. She had documented cerebral and meningeal metastases that were progressing despite chemotherapy and radiotherapy. The admitting physician met with her family and suggested a palliative approach, making them very upset. The family insisted that the team 'do everything' and now they refuse to discuss any change in the plan of treatment. They maintain a constant presence at the bedside, taking notes and questioning everyone who enters the room. They have threatened legal action toward several of the nursing staff, and hospital security has been called twice because of shouting matches between family and staff members. As the physician taking over care for the ICU, you would like to resolve this conflict.

Skeletal Muscle Ultrasound in Critical Care: A Tool in Need of Translation.

PubMed

Mourtzakis, Marina; Parry, Selina; Connolly, Bronwen; Puthucheary, Zudin

2017-10-01

With the emerging interest in documenting and understanding muscle atrophy and function in critically ill patients and survivors, ultrasonography has transformational potential for measurement of muscle quantity and quality. We discuss the importance of quantifying skeletal muscle in the intensive care unit setting. We also identify the merits and limitations of various modalities that are capable of accurately and precisely measuring muscularity. Ultrasound is emerging as a potentially powerful tool for skeletal muscle quantification; however, there are key challenges that need to be addressed in future work to ensure useful interpretation and comparability of results across diverse observational and interventional studies. Ultrasound presents several methodological challenges, and ultimately muscle quantification combined with metabolic, nutritional, and functional markers will allow optimal patient assessment and prognosis. Moving forward, we recommend that publications include greater detail on landmarking, repeated measures, identification of muscle that was not assessable, and reproducible protocols to more effectively compare results across different studies.

Improving and Measuring Inpatient Documentation of Medical Care within the MS-DRG System: Education, Monitoring, and Normalized Case Mix Index

PubMed Central

Rosenbaum, Benjamin P.; Lorenz, Robert R.; Luther, Ralph B.; Knowles-Ward, Lisa; Kelly, Dianne L.; Weil, Robert J.

2014-01-01

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the “normalized case mix index,” that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved. PMID:25214820

Improving and measuring inpatient documentation of medical care within the MS-DRG system: education, monitoring, and normalized case mix index.

PubMed

Rosenbaum, Benjamin P; Lorenz, Robert R; Luther, Ralph B; Knowles-Ward, Lisa; Kelly, Dianne L; Weil, Robert J

2014-01-01

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the "normalized case mix index," that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved.

Advance Care Planning Documentation in Electronic Health Records: Current Challenges and Recommendations for Change.

PubMed

Lamas, Daniela; Panariello, Natalie; Henrich, Natalie; Hammes, Bernard; Hanson, Laura C; Meier, Diane E; Guinn, Nancy; Corrigan, Janet; Hubber, Sean; Luetke-Stahlman, Hannah; Block, Susan

2018-04-01

To develop a set of clinically relevant recommendations to improve the state of advance care planning (ACP) documentation in the electronic health record (EHR). Advance care planning (ACP) is a key process that supports goal-concordant care. For preferences to be honored, clinicians must be able to reliably record, find, and use ACP documentation. However, there are no standards to guide ACP documentation in the electronic health record (EHR). We interviewed 21 key informants to understand the strengths and weaknesses of EHR documentation systems for ACP and identify best practices. We analyzed these interviews using a qualitative content analysis approach and subsequently developed a preliminary set of recommendations. These recommendations were vetted and refined in a second round of input from a national panel of content experts. Informants identified six themes regarding current inadequacies in documentation and accessibility of ACP information and opportunities for improvement. We offer a set of concise, clinically relevant recommendations, informed by expert opinion, to improve the state of ACP documentation in the EHR.

Quality Of End-Of-Life Care Is Higher In The VA Compared To Care Paid For By Traditional Medicare.

PubMed

Gidwani-Marszowski, Risha; Needleman, Jack; Mor, Vincent; Faricy-Anderson, Katherine; Boothroyd, Derek B; Hsin, Gary; Wagner, Todd H; Lorenz, Karl A; Patel, Manali I; Joyce, Vilija R; Murrell, Samantha S; Ramchandran, Kavitha; Asch, Steven M

2018-01-01

Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.

Impact of mobile intensive care unit use on total ischemic time and clinical outcomes in ST-elevation myocardial infarction patients - real-world data from the Acute Coronary Syndrome Israeli Survey.

PubMed

Koifman, Edward; Beigel, Roy; Iakobishvili, Zaza; Shlomo, Nir; Biton, Yitschak; Sabbag, Avi; Asher, Elad; Atar, Shaul; Gottlieb, Shmuel; Alcalai, Ronny; Zahger, Doron; Segev, Amit; Goldenberg, Ilan; Strugo, Rafael; Matetzky, Shlomi

2017-01-01

Ischemic time has prognostic importance in ST-elevation myocardial infarction patients. Mobile intensive care unit use can reduce components of total ischemic time by appropriate triage of ST-elevation myocardial infarction patients. Data from the Acute Coronary Survey in Israel registry 2000-2010 were analyzed to evaluate factors associated with mobile intensive care unit use and its impact on total ischemic time and patient outcomes. The study comprised 5474 ST-elevation myocardial infarction patients enrolled in the Acute Coronary Survey in Israel registry, of whom 46% ( n=2538) arrived via mobile intensive care units. There was a significant increase in rates of mobile intensive care unit utilization from 36% in 2000 to over 50% in 2010 ( p<0.001). Independent predictors of mobile intensive care unit use were Killip>1 (odds ratio=1.32, p<0.001), the presence of cardiac arrest (odds ratio=1.44, p=0.02), and a systolic blood pressure <100 mm Hg (odds ratio=2.01, p<0.001) at presentation. Patients arriving via mobile intensive care units benefitted from increased rates of primary reperfusion therapy (odds ratio=1.58, p<0.001). Among ST-elevation myocardial infarction patients undergoing primary reperfusion, those arriving by mobile intensive care unit benefitted from shorter median total ischemic time compared with non-mobile intensive care unit patients (175 (interquartile range 120-262) vs 195 (interquartile range 130-333) min, respectively ( p<0.001)). Upon a multivariate analysis, mobile intensive care unit use was the most important predictor in achieving door-to-balloon time <90 min (odds ratio=2.56, p<0.001) and door-to-needle time <30 min (odds ratio=2.96, p<0.001). One-year mortality rates were 10.7% in both groups (log-rank p-value=0.98), however inverse propensity weight model, adjusted for significant differences between both groups, revealed a significant reduction in one-year mortality in favor of the mobile intensive care unit group (odds ratio=0.79, 95% confidence interval (0.66-0.94), p=0.01). Among patients with ST-elevation myocardial infarction, the utilization of mobile intensive care units is associated with increased rates of primary reperfusion, a reduction in the time interval to reperfusion, and a reduction in one-year adjusted mortality.

Electronic Nursing Documentation: Patient Care Continuity Using the Clinical Care Classification System (CCC).

PubMed

Whittenburg, Luann; Meetim, Aunchisa

2016-01-01

An innovative nursing documentation project conducted at Bumrungrad International Hospital in Bangkok, Thailand demonstrated patient care continuity between nursing patient assessments and nursing Plans of Care using the Clinical Care Classification System (CCC). The project developed a new generation of interactive nursing Plans of Care using the six steps of the American Nurses Association (ANA) Nursing process and the MEDCIN^® clinical knowledgebase to present CCC coded concepts as a natural by-product of a nurse's documentation process. The MEDCIN^® clinical knowledgebase is a standardized point-of-care terminology intended for use in electronic health record systems. The CCC is an ANA recognized nursing terminology.

The changing pattern of prenatal care utilization in the United States, 1981-1995, using different prenatal care indices.

PubMed

Kogan, M D; Martin, J A; Alexander, G R; Kotelchuck, M; Ventura, S J; Frigoletto, F D

1998-05-27

Two measures traditionally used to examine adequacy of prenatal care indicate that prenatal care utilization remained unchanged through the 1980s and only began to rise slightly in the 1990s. In recent years, new measures have been developed that include a category for women who receive more than the recommended amount of care (intensive utilization). To compare the older and newer indices in the monitoring of prenatal care trends in the United States from 1981 to 1995, for the overall population and for selected subpopulations. Second, to examine factors associated with receiving intensive utilization. Cross-sectional and trend analysis of national birth records. The United States. All live births between 1981 and 1995 (N=54 million). Trends in prenatal care utilization, according to 4 indices (the older indices: the Institute of Medicine Index and the trimester that care began, and the newer indices: the R-GINDEX and the Adequacy of Prenatal Care Utilization Index). Multiple logistic regression was used to assess the risk of intensive prenatal care use in 1981 and 1995. The newer indices showed a steadily increasing trend toward more prenatal care use throughout the study period (R-GINDEX, intensive or adequate use, 32.7% in 1981 to 47.1 % in 1995; the Adequacy of Prenatal Care Utilization Index, intensive use, 18.4% in 1981 to 28.8% in 1995), especially for intensive utilization. Women having a multiple birth were much more likely to have had intensive utilization in 1995 compared with 1981 (R-GINDEX, 22.8% vs 8.5%). Teenagers were more likely to begin care later than adults, but similar proportions of teens and adults had intensive utilization. Intensive use among low-risk women also increased steadily each year. Factors associated with a greater likelihood of receiving intensive use in 1981 and 1995 were having a multiple birth, primiparity, being married, and maternal age of 35 years or older. The proportion of women who began care early and received at least the recommended number of visits increased between 1981 and 1995. This change was undetected by more traditional prenatal care indices. These increases have cost and practice implications and suggest a paradox since previous studies have shown that rates of preterm delivery and low birth weight did not improve during this time.

Financial hardship and the intensity of medical care received near death.

PubMed

Tucker-Seeley, Reginald D; Abel, Gregory A; Uno, Hajime; Prigerson, Holly

2015-05-01

Although end-of-life (EOL) care can present a substantial financial burden for the household, the influence of this burden on the intensity of care received at the EOL remains unknown. The goal of this study was to determine the association between financial hardship and intensive care in the last week of life. The Coping with Cancer (CwC) Study is a longitudinal, multisite cohort study of terminally ill cancer patients and their informal caregivers, September 2002-February 2008. Patients (N = 281) were followed from baseline to death, a median of 4.4 months after baseline assessment. Intensive care was defined as the use of resuscitation and/or ventilation in the patient's last week of life. Financial hardship was measured at study baseline as a positive response to whether the household had to use all or most of their savings because of the family member's illness. Twenty-nine percent reported financial hardship, and 9% received intensive EOL care. Patients reporting financial hardship had a 3.22 (95% CI: 1.38, 7.53) higher likelihood of receiving intensive EOL care compared with patients not reporting financial hardship. After adjusting for sociodemographic characteristics and patient preferences, patients reporting financial hardship had a 3.05 (95% CI: 1.22, 7.62) higher likelihood of receiving intensive EOL care. The depletion of a family's financial resources is a significant predictor of intensive EOL care, over and above the influence of sociodemographic characteristics and patient preferences. Copyright © 2014 John Wiley & Sons, Ltd.

Renal replacement therapy in adult and pediatric intensive care : Recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD).

PubMed

Vinsonneau, Christophe; Allain-Launay, Emma; Blayau, Clarisse; Darmon, Michael; Ducheyron, Damien; Gaillot, Theophile; Honore, Patrick M; Javouhey, Etienne; Krummel, Thierry; Lahoche, Annie; Letacon, Serge; Legrand, Matthieu; Monchi, Mehran; Ridel, Christophe; Robert, René; Schortgen, Frederique; Souweine, Bertrand; Vaillant, Patrick; Velly, Lionel; Osman, David; Van Vong, Ly

2015-12-01

Acute renal failure (ARF) in critically ill patients is currently very frequent and requires renal replacement therapy (RRT) in many patients. During the last 15 years, several studies have considered important issues regarding the use of RRT in ARF, like the time to initiate the therapy, the dialysis dose, the types of catheter, the choice of technique, and anticoagulation. However, despite an abundant literature, conflicting results do not provide evidence on RRT implementation. We present herein recommendations for the use of RRT in adult and pediatric intensive care developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of French Intensive Care Society (SRLF), with the participation of the French Society of Anesthesia and Intensive Care (SFAR), the French Group for Pediatric Intensive Care and Emergencies (GFRUP), and the French Dialysis Society (SFD). The recommendations cover 4 fields: criteria for RRT initiation, technical aspects (access routes, membranes, anticoagulation, reverse osmosis water), practical aspects (choice of the method, peritoneal dialysis, dialysis dose, adjustments), and safety (procedures and training, dialysis catheter management, extracorporeal circuit set-up). These recommendations have been designed on a practical point of view to provide guidance for intensivists in their daily practice.

[Environmental noise levels in 2 intensive care units in a tertiary care centre].

PubMed

Ornelas-Aguirre, José Manuel; Zárate-Coronado, Olivia; Gaxiola-González, Fabiola; Neyoy-Sombra, Venigna

2017-04-03

The World Health Organisation (WHO) has established a maximum noise level of 40 decibels (dB) for an intensive care unit. The aim of this study was to compare the noise levels in 2 different intensive care units at a tertiary care centre. Using a cross-sectional design study, an analysis was made of the maximum noise level was within the intensive coronary care unit and intensive care unit using a digital meter. A measurement was made in 4 different points of each room, with 5minute intervals, for a period of 60minutes 7:30, 14:30, and 20:30. The means of the observations were compared with descriptive statistics and Mann-Whitney U. An analysis with Kruskal-Wallis test was performed to the mean noise level. The noise observed in the intensive care unit had a mean of 64.77±3.33dB (P=.08), which was similar to that in the intensive coronary care unit, with a mean of 60.20±1.58dB (P=.129). Around 25% or more of the measurements exceeded the level recommended by the WHO by up to 20 points. Noise levels measured in intensive care wards exceed the maximum recommended level for a hospital. It is necessary to design and implement actions for greater participation of health personnel in the reduction of environmental noise. Copyright © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.

New concepts in palliative care in the intensive care unit

PubMed Central

Coelho, Cristina Bueno Terzi; Yankaskas, James R.

2017-01-01

Some patients admitted to an intensive care unit may face a terminal illness situation, which usually leads to death. Knowledge of palliative care is strongly recommended for the health care providers who are taking care of these patients. In many situations, the patients should be evaluated daily as the introduction of further treatments may not be beneficial to them. The discussions among health team members that are related to prognosis and the goals of care should be carefully evaluated in collaboration with the patients and their families. The adoption of protocols related to end-of-life patients in the intensive care unit is fundamental. A multidisciplinary team is important for determining whether the withdrawal or withholding of advanced care is required. In addition, patients and families should be informed that palliative care involves the best possible care for that specific situation, as well as respect for their wishes and the consideration of social and spiritual backgrounds. Thus, the aim of this review is to present palliative care as a reasonable option to support the intensive care unit team in assisting terminally ill patients. Updates regarding diet, mechanical ventilation, and dialysis in these patients will be presented. Additionally, the hospice-model philosophy as an alternative to the intensive care unit/hospital environment will be discussed. PMID:28977262

Adjustment of inpatient care reimbursement for nursing intensity.

PubMed

Welton, John M; Zone-Smith, Laurie; Fischer, Mary H

2006-11-01

The Centers for Medicare and Medicaid Services has begun an ambitious recalibration of the inpatient prospective payment system, the first since its introduction in 1983. Unfortunately, inpatient nursing care has been overlooked in the new payment system and continues to be treated as a fixed cost and billed at a set per-diem "room and board" fee despite the known variability of nursing intensity across different care settings and diagnoses. This article outlines the historical influences regarding costing, billing, and reimbursement of inpatient nursing care and provides contemporary evidence about the variability of nursing intensity and costs at acute care hospitals in the United States. A remedy is proposed to overcome the existing limitations of the Inpatient Prospective Payment System by creating a new nursing cost center and nursing intensity adjustment by DRG for each routine-and intensive-care day of stay to allow independent costing, billing, and reimbursement of inpatient nursing care.

The match between institutional elderly care management research and management challenges - a systematic literature review.

PubMed

Kokkonen, Kaija; Rissanen, Sari; Hujala, Anneli

2012-11-08

Elderly care practice and its management together with policy and research play a crucial role in responding to increasing challenges in institutional care for elderly people. Successful dialogue between these is necessary. The purpose of this systematic literature review is to compare how institutional elderly care management research meets the care challenges currently emphasized in international long-term care policy documents. This paper was based on a systematic literature review. After screening 1971 abstracts using inclusion/exclusion criteria, 58 refereed articles published between 2000 and 2010 remained for analysis. The articles were analyzed using theory-based content analysis by comparing the results to the framework based on analysis of international long-term care management policy documents. The current challenges of long-term care management identified from policy documents were Integrated Care Management, Productivity Management, Quality Management, Workforce Management and ICT Management. The research on institutional elderly care management responded somewhat to the challenges mentioned in policy documents. However, some of the challenges were studied broadly and some were paid only minor attention. Further, only few studies focused on the core items of challenges addressed in policy documents. Institutional care management research needs to focus more on challenges in integrated care, productivity, ICT and division of labor. Managers, researchers and policy-makers should assume more active collaborative roles in processes of research, policymaking and policy implementation. In addition managers' and policymakers' scientific literacy needs to be enhanced.

The match between institutional elderly care management research and management challenges - a systematic literature review

PubMed Central

2012-01-01

Background Elderly care practice and its management together with policy and research play a crucial role in responding to increasing challenges in institutional care for elderly people. Successful dialogue between these is necessary. The purpose of this systematic literature review is to compare how institutional elderly care management research meets the care challenges currently emphasized in international long-term care policy documents. Methods This paper was based on a systematic literature review. After screening 1971 abstracts using inclusion/exclusion criteria, 58 refereed articles published between 2000 and 2010 remained for analysis. The articles were analyzed using theory-based content analysis by comparing the results to the framework based on analysis of international long-term care management policy documents. Results The current challenges of long-term care management identified from policy documents were Integrated Care Management, Productivity Management, Quality Management, Workforce Management and ICT Management. The research on institutional elderly care management responded somewhat to the challenges mentioned in policy documents. However, some of the challenges were studied broadly and some were paid only minor attention. Further, only few studies focused on the core items of challenges addressed in policy documents. Conclusions Institutional care management research needs to focus more on challenges in integrated care, productivity, ICT and division of labor. Managers, researchers and policy-makers should assume more active collaborative roles in processes of research, policymaking and policy implementation. In addition managers’ and policymakers’ scientific literacy needs to be enhanced. PMID:23137416

Migrant and minority family members in the intensive care unit. A review of the literature

PubMed Central

Quindemil, KettyElena; Anderson, Kathryn Hoehn; Mayer, Hanna

2013-01-01

Statistics show that people with migrant and minority background as patients are significant in numbers in the intensive care unit. This also puts family members in the perspective of nursing because family members are an inherent part of the intensive care unit. Family-centered care is perhaps most applicable to vulnerable populations like migrant family in the intensive care unit to meet family member’s needs. But very little is known about the situation of migrant and minority family members in the intensive care unit. The aim of the study was to explore the state of the science regarding family-centered care in the intensive care unit of patients with migration background in general and with a possible focus on major migrant populations in Austria—Former Yugoslavian und Turkish origin. A literature review investigated research articles that contained information on migrant and minority family members in the intensive care unit. Key points in the relevant articles were identified and categorized into themes with an explanation of findings at the end. Seventeen articles fulfilled the inclusion criteria. No article was found regarding groups of major migrant population groups in Austria. The included articles uncovered five predominant themes: importance of cultural norms, communication, family dynamics, universal caring, and nursing/provider deficit in culturally competent care. In order to provide adequate nursing care a more cohesive body of information on more specific geographic and cultural populations is recommended. Because of the complete lack of research regarding migrant families of Former Yugoslavian and Turkish origin into Austria, an exploration of this population is recommended. PMID:24860716

Infant Mental Health for Medically Fragile Babies in Intensive Care and Their Families

ERIC Educational Resources Information Center

Browne, Joy V.; Talmi, Ayelet

2017-01-01

Infants who begin their lives in intensive care are impacted physically and socioemotionally for many months and years to come. Likewise, stressful experiences of caring for a baby hospitalized in intensive care have an impact on primary caregivers, typically the baby's parents. Infant mental health (IMH) is an expanding, evidence-based field that…

[A scale for the assessment of the risk of pressure sores in paediatric intensive care].

PubMed

Weigel, Virginie

2014-01-01

Pressure sores are a frequent complication in paediatric intensive care. A multi-disciplinary nursing team has drawn up an assessment scale for the risk of pressure sores and has put in place guidelines for caring for children in intensive care. Prevention actions are thereby adapted to each young patient.

Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005.

PubMed

Davidson, Judy E; Powers, Karen; Hedayat, Kamyar M; Tieszen, Mark; Kon, Alexander A; Shepard, Eric; Spuhler, Vicki; Todres, I David; Levy, Mitchell; Barr, Juliana; Ghandi, Raj; Hirsch, Gregory; Armstrong, Deborah

2007-02-01

To develop clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU. A multidisciplinary task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM) to include representation from adult, pediatric, and neonatal intensive care units. The task force members reviewed the published literature. The Cochrane library, Cinahl, and MedLine were queried for articles published between 1980 and 2003. Studies were scored according to Cochrane methodology. Where evidence did not exist or was of a low level, consensus was derived from expert opinion. The topic was divided into subheadings: decision making, family coping, staff stress related to family interactions, cultural support, spiritual/religious support, family visitation, family presence on rounds, family presence at resuscitation, family environment of care, and palliative care. Each section was led by one task force member. Each section draft was reviewed by the group and debated until consensus was achieved. The draft document was reviewed by a committee of the Board of Regents of the ACCM. After steering committee approval, the draft was approved by the SCCM Council and was again subjected to peer review by this journal. More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death.

[Intensive and palliative care medicine. From academic distance to caring affection].

PubMed

Burchardi, H

2014-02-01

Intensive care medicine has made great contributions to the immense success of modern curative medicine. However, emotional care and empathy for the patient and his family seem to be sparse. There is an assumed constraint to objectivity and efficiency, as well as a massive economic pressure which transfers the physician into an agent of the disease instead of a trustee of the ill human being. The physician struggles against the disease and feels the death of his patient as his personal defeat. However, in futile situations the intensivist must learn to let go. He is responsible for futile overtreatment as well as for successful treatment. Today, in futile situations in the intensive care unit (ICU), it is possible to change the goal from curative treatment to palliative care. This is a consequent further development from critical care medicine. In end-of-life situations in the intensive care unit, emotional care and empathy are mandatory using intensive dialogues with the family. Despite great workload stress enough time for such conversation should be taken, because the physician will generously be repaid by the way he sees his medical activity. The maintenance of a culture of empathy within the intensive care team is a major task for the leader. In this manner, the ICU will become and remain a place for living humanity.

[Quality assurance in intensive care: the situation in Switzerland].

PubMed

Frutiger, A

1999-10-30

The movement for quality in medicine is starting to take on the dimensions of a crusade. Quite logically it has also reached the intensive care community. Due to their complex multidisciplinary functioning and because of the high costs involved, ICUs are model services reflecting the overall situation in our hospitals. The situation of Swiss intensive care is particularly interesting, because for over 25 years standards for design and staffing of Swiss ICUs have been in effect and were enforced via onsite visits by the Swiss Society of Intensive Care without government involvement. Swiss intensive care thus defined its structures long before the word "accreditation" had even been used in this context. While intensive care in Switzerland is practised in clearly defined, well equipped and adequately staffed units, much less is known about process quality and outcomes of these services. Statistics on admissions, length of stay and length of mechanical ventilation, as well as severity data based on a simple classification system, are collected nationwide and allow some limited insight into the overall process of care. Results of intensive care are not systematically assessed. In response to the constant threat of cost containment, Swiss ICUs should increasingly focus on process quality and results, while maintaining their existing good structures.

Discharge prescribing of enteral opioids after initiation as a weaning strategy from continuous opioid infusions in the Intensive Care Unit.

PubMed

Kram, Bridgette; Weigel, Kylie M; Kuhrt, Michelle; Gilstrap, Daniel L

To evaluate the proportion of patients receiving a hospital discharge prescription for a scheduled enteral opioid following initiation as a weaning strategy from a continuous opioid infusion in the Intensive Care Unit (ICU). Retrospective, observational study. Five adult ICUs at a large, quaternary care academic medical center. Endotracheally intubated, opioid-naive adults receiving a continuous opioid infusion with a concomitant scheduled enteral opioid initiated. Exclusion criteria were receipt of fewer than two enteral opioid doses, documentation of a long-acting opioid as a home medication, the indication for the enteral opioid was not a weaning strategy, death during hospital admission or discharge to hospice. None. The proportion of ICU and hospital survivors who received a discharge prescription for a scheduled enteral opioid, total duration of continuous opioid infusion, duration of continuous opioid infusion after initiation of an enteral opioid therapy, total duration of enteral therapy, ICU and hospital length of stay. Of 62 included patients, 19 patients (30.6 percent) received a new prescription for a scheduled enteral opioid at hospital discharge. The median duration of enteral opioid therapy was longer for patients who received a discharge prescription compared to those who did not (20.09 vs 8.89 days, p = 0.02), though the remaining endpoints were not different. Utilizing scheduled enteral opioids as a weaning strategy from continuous opioid infusions may place patients at risk of ICU-acquired physical dependence on opioids.

Skin Rounds: A Quality Improvement Approach to Enhance Skin Care in the Neonatal Intensive Care Unit.

PubMed

Nist, Marliese Dion; Rodgers, Elizabeth A; Ruth, Brenda M; Bertoni, C Briana; Bartman, Thomas; Keller, Leah A; Dail, James W; Gardikes-Gingery, Renee; Shepherd, Edward G

2016-10-01

Skin injuries are common among neonatal intensive care unit (NICU) patients and may lead to significant complications. Standardized methods of preventing, detecting, and treating skin injuries are needed. The aim of this project was to standardize the assessment, documentation, and tracking of skin injuries among hospitalized neonatal patients and to determine the incidence of pressure ulcers in this patient population. (1) Creation of an interdisciplinary skin team to identify skin injuries through weekly skin rounds. (2) Assessment of all patients at least twice daily for the presence of skin injuries. Interventions were implemented upon identification of a skin injury. Pressure ulcers of Stage II or more were further assessed by wound/ostomy nurses. A total of 2299 NICU patients were hospitalized and assessed between July 2011 and December 2015. After the initiation of skin rounds, the baseline incidence of pressure ulcers increased from 0.49 per 1000 patient days to 4.6 per 1000 patient days, reflecting an improvement in detection and reporting. The most common skin injuries detected included erythema, skin tears, and ecchymosis; the most common cause of injuries was medical devices. A dedicated skin team can improve the detection and reporting of skin injuries among NICU patients. Determination of the incidence of pressure ulcers in this population is critical to develop targeted interventions. Further research is needed to determine the most effective interventions to prevent and treat skin injuries among hospitalized neonates.

Child Care and Education: The Critical Connection. Action Plan [and] Policy Statement.

ERIC Educational Resources Information Center

Child Care Action Campaign, New York, NY.

This document presents the action plan of the Child Care Action Campaign (CCAC) for improving the quantity and quality of child care services. The document also provides a policy statement on linking education and child care efforts. The action plan describes CCAC's vision of a streamlined system providing child care to infants and toddlers,…

Withholding treatment, withdrawing treatment, and palliative care in the neonatal intensive care unit.

PubMed

Walther, Frans J

2005-12-01

Advances in pharmacology and technology have sharply reduced mortality of extremely preterm infants at the expense of an increasing number of survivors with handicaps and disabilities. The EURONIC study among neonatal intensive care units across Europe demonstrates that treatment of infants born at the limits of viability raises challenging ethical, moral, legal, and emotional dilemmas among neonatologists, nurses, and parents alike. When is it wise to withhold or withdraw intensive care and, if so, what are the needs of the nonviable or dying infant, family, and neonatal staff to provide a humane and compassionate death? This process begins with a thorough determination of diagnosis and prognosis, followed by decision making on the basis of futility of treatment or quality-of-life issues, and counseling of parents. Withholding or withdrawing of intensive care should be synonymous with palliative care. Perinatal audit and after-care of the family complete the process. The Dutch viewpoint and practice guidelines on withholding and withdrawing of neonatal intensive care are presented.

Sleep and sedation in the pediatric intensive care unit.

PubMed

Carno, Margaret-Ann; Connolly, Heidi V

2005-09-01

Sleep is an important and necessary function of the human body. Somatic growth and cellular repair occur during sleep. Critically ill children have disturbed sleep while in the pediatric intensive care unit related both to the illness itself and to light, noise, and caregiver activities disrupting an environment conducive to sleep. Medications administered in the pediatric intensive care unit can also disrupt sleep. This article reviews what is known about sleep in the pediatric intensive care unit and the effects of common sedation medications on sleep.

[Position paper of the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN) on medical intensive care medicine].

PubMed

Riessen, R; Janssens, U; Buerke, M; Kluge, S

2016-05-01

In this paper the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN) provides statements regarding the importance and advancement of Medical Intensive Care Medicine within the structures of Internal Medicine in Germany. Of pivotal importance are the training of medical intensivists, the cooperation with intensivists from other disciplines and the collaboration with emergency departments. In order to fulfil the various and challenging tasks in patient care, training, research and medical education competently and on an international level, more intensivists in leading positions especially in academic institutions are essential.

Child Care Centres.

ERIC Educational Resources Information Center

Australian Dept. of Labour and National Service, Melbourne. Women's Bureau.

This document is an English-language abstract (approximately 1,500 words) in which Australian child care facilities are surveyed to include those providing full-day care and therefore excludes kindergartens, play centers, nursery schools, and child minding centers that provide care for only part of the day. The document presents a breakdown of…

Factors potentially associated with the decision of admission to the intensive care unit in a middle-income country: a survey of Brazilian physicians.

PubMed

Ramos, João Gabriel Rosa; Passos, Rogerio da Hora; Baptista, Paulo Benigno Pena; Forte, Daniel Neves

2017-01-01

To evaluate the factors potentially associated with the decision of admission to the intensive care unit in Brazil. An electronic survey of Brazilian physicians working in intensive care units. Fourteen variables that were potentially associated with the decision of admission to the intensive care unit were rated as important (from 1 to 5) by the respondents and were later grouped as "patient-related," "scarcity-related" and "administrative-related" factors. The workplace and physician characteristics were evaluated for correlation with the factor ratings. During the study period, 125 physicians completed the survey. The scores on patient-related factors were rated higher on their potential to affect decisions than scarcity-related or administrative-related factors, with a mean ± SD of 3.42 ± 0.7, 2.75 ± 0.7 and 2.87 ± 0.7, respectively (p < 0.001). The patient's underlying illness prognosis was rated by 64.5% of the physicians as always or frequently affecting decisions, followed by acute illness prognosis (57%), number of intensive care unit beds available (56%) and patient's wishes (53%). After controlling for confounders, receiving specific training on intensive care unit triage was associated with higher ratings of the patient-related factors and scarcity-related factors, while working in a public intensive care unit (as opposed to a private intensive care unit) was associated with higher ratings of the scarcity-related factors. Patient-related factors were more frequently rated as potentially affecting intensive care unit admission decisions than scarcity-related or administrative-related factors. Physician and workplace characteristics were associated with different factor ratings.

Factors potentially associated with the decision of admission to the intensive care unit in a middle-income country: a survey of Brazilian physicians

PubMed Central

Ramos, João Gabriel Rosa; Passos, Rogerio da Hora; Baptista, Paulo Benigno Pena; Forte, Daniel Neves

2017-01-01

Objective To evaluate the factors potentially associated with the decision of admission to the intensive care unit in Brazil. Methods An electronic survey of Brazilian physicians working in intensive care units. Fourteen variables that were potentially associated with the decision of admission to the intensive care unit were rated as important (from 1 to 5) by the respondents and were later grouped as "patient-related," "scarcity-related" and "administrative-related" factors. The workplace and physician characteristics were evaluated for correlation with the factor ratings. Results During the study period, 125 physicians completed the survey. The scores on patient-related factors were rated higher on their potential to affect decisions than scarcity-related or administrative-related factors, with a mean ± SD of 3.42 ± 0.7, 2.75 ± 0.7 and 2.87 ± 0.7, respectively (p < 0.001). The patient's underlying illness prognosis was rated by 64.5% of the physicians as always or frequently affecting decisions, followed by acute illness prognosis (57%), number of intensive care unit beds available (56%) and patient's wishes (53%). After controlling for confounders, receiving specific training on intensive care unit triage was associated with higher ratings of the patient-related factors and scarcity-related factors, while working in a public intensive care unit (as opposed to a private intensive care unit) was associated with higher ratings of the scarcity-related factors. Conclusions Patient-related factors were more frequently rated as potentially affecting intensive care unit admission decisions than scarcity-related or administrative-related factors. Physician and workplace characteristics were associated with different factor ratings. PMID:28977256

Organizational and Teamwork Factors of Tele-Intensive Care Units.

PubMed

Wilkes, Michael S; Marcin, James P; Ritter, Lois A; Pruitt, Sherilyn

2016-09-01

Use of tele-intensive care involves organizational and teamwork factors across geographic locations. This situation adds to the complexity of collaboration in providing quality patient-centered care. To evaluate cross-agency teamwork of health care professionals caring for patients in tele-intensive care units in rural and urban regions. A national qualitative study was conducted in 3 US geographic regions with tele-intensive care programs. Discussions and interviews were held with key participants during site visits at 3 hub sites (specialist services location) and 8 rural spoke sites (patient location). The effects of communication and culture between the hub team and the spoke team on use of the services and effectiveness of care were evaluated. A total of 34 participants were interviewed. Specific organizational and teamwork factors significantly affect the functionality of a tele-intensive care unit. Key operational and cultural barriers that limit the benefits of the units include unrealistic expectations about operational capabilities, lack of trust, poorly defined leadership, and a lack of communication policies. Potential solutions include education on spoke facility resources, clearly defined expectations and role reversal education, team-building activities, and feedback mechanisms to share concerns, successes, and suggestions. Proper administration and attention to important cultural and teamwork factors are essential to making tele-intensive care units effective, practical, and sustainable. ©2016 American Association of Critical-Care Nurses.

Perinatal regionalization versus hospital competition: the Hartford example.

PubMed

Richardson, D K; Reed, K; Cutler, J C; Boardman, R C; Goodman, K; Moynihan, T; Driscoll, J; Raye, J R

1995-09-01

The increasingly competitive health care environment may undermine effective traditional regional organizations. It is urgent to document the benefits of perinatal regionalization for the emerging health care system. We present a case study that illustrates many of the challenges to and benefits of perinatal regionalization in the 1990s. The controversy in Hartford was sparked by a proposed merger of two major pediatric services into a full-service children's hospital. Community hospitals reacted with plans to upgrade their obstetrics/neonatal facilities toward level II (intermediate) or II+ (intensive) neonatal intensive care units (NICUs). The fear that unrestricted competition would drive up overall health care costs prompted the hospital association and Chamber of Commerce to retain consultants to evaluate the number and location of regional NICU beds. The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges. The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization. Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.

Nature of nursing errors and their contributing factors in intensive care units.

PubMed

Eltaybani, Sameh; Mohamed, Nadia; Abdelwareth, Mona

2018-04-27

Errors tend to be multifactorial and so learning from nurses' experiences with them would be a powerful tool toward promoting patient safety. To identify the nature of nursing errors and their contributing factors in intensive care units (ICUs). A semi-structured interview with 112 critical care nurses to elicit the reports about their encountered errors followed by a content analysis. A total of 300 errors were reported. Most of them (94·3%) were classified in more than one error category, e.g. 'lack of intervention', 'lack of attentiveness' and 'documentation errors': these were the most frequently involved error categories. Approximately 40% of reported errors contributed to significant harm or death of the involved patients, with system-related factors being involved in 84·3% of them. More errors occur during the evening shift than the night and morning shifts (42·7% versus 28·7% and 16·7%, respectively). There is a statistically significant relation (p ≤ 0·001) between error disclosure to a nursing supervisor and its impact on the patient. Nurses are more likely to report their errors when they feel safe and when the reporting system is not burdensome, although an internationally standardized language to define and analyse nursing errors is needed. Improving the health care system, particularly the managerial and environmental aspects, might reduce nursing errors in ICUs in terms of their incidence and seriousness. Targeting error-liable times in the ICU, such as mid-evening and mid-night shifts, along with improved supervision and adequate staff reallocation, might tackle the incidence and seriousness of nursing errors. Development of individualized nursing interventions for patients with low health literacy and patients in isolation might create more meaningful dialogue for ICU health care safety. © 2018 British Association of Critical Care Nurses.

Does incorporation of a clinical support template in the electronic medical record improve capture of wound care data in a cohort of veterans with diabetic foot ulcers?

PubMed

Lowe, Jeanne R; Raugi, Gregory J; Reiber, Gayle E; Whitney, Joanne D

2013-01-01

The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention. From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding. The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001). An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.

Electronic document management systems: an overview.

PubMed

Kohn, Deborah

2002-08-01

For over a decade, most health care information technology (IT) professionals erroneously learned that document imaging, which is one of the many component technologies of an electronic document management system (EDMS), is the only technology of an EDMS. In addition, many health care IT professionals erroneously believed that EDMSs have either a limited role or no place in IT environments. As a result, most health care IT professionals do not understand documents and unstructured data and their value as structured data partners in most aspects of transaction and information processing systems.

Healthcare improvement as planned system change or complex responsive processes? a longitudinal case study in general practice

PubMed Central

2013-01-01

Background Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens. Methods This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology. Results The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives – re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices. Conclusions The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare. PMID:23617833

Insulin therapy in the pediatric intensive care unit

USDA-ARS?s Scientific Manuscript database

Hyperglycemia is a major risk factor for increased morbidity and mortality in the intensive care unit. Insulin therapy has emerged in adult intensive care units, and several pediatric studies are currently being conducted. This review discusses hyperglycemia and the effects of insulin on metabolic a...

Family-centred care in the paediatric intensive care unit: an integrative review of the literature.

PubMed

Butler, Ashleigh; Copnell, Beverley; Willetts, Georgina

2014-08-01

To review extant research on family-centred care in a paediatric intensive care environment and identify gaps in the literature. Family-centred care is currently a core concept in paediatric nursing, focusing on the premise that families are central to a child's well-being, and as such, should be included as equal members of the child's healthcare team. Due to the nature of critical care, family-centred care may be challenging to implement and maintain. An integrative literature review. The review was conducted using the Cumulative Index to Nursing and Allied Health Literature, PubMed, OVID MEDLINE and Google Scholar databases, from 1990 to present. The search focused on the following terms: 'p(a)ediatric critical care', 'paediatric intensive care unit', 'family cent(e)red care', 'parental needs', 'family presence' and 'family/nurse roles'. Additionally, the search was limited to studies conducted in a developed country and published in English. Eighteen studies were included in the review. The results demonstrated that implementing family-centred care into a paediatric intensive care environment posed several challenges. The discrepancy between nurses' and parents' perception of their roles, the reluctance of medical staff to share potentially negative or rapidly changing information, restrictive family presence and poor understanding of family needs emerged as the key difficulties. No studies evaluated strategies to improve family-centred care practice. Family-centred care presents many challenges in a paediatric intensive care environment; however, nurses are uniquely positioned to foster relationships with families, encourage accurate and honest information sharing and advocate for families to be present when they choose. This review outlines the extant research to enhance awareness of the unique state of family-centred care in paediatric intensive care and makes recommendations for future research. © 2013 John Wiley & Sons Ltd.

Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act

PubMed Central

Logani, Sachin; Green, Adam; Gasperino, James

2011-01-01

The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU) are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees) and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform. PMID:22110908

Pre-Intensive Care Unit Cognitive Status, Subsequent Disability, and New Nursing Home Admission among Critically Ill Older Adults.

PubMed

Ferrante, Lauren E; Murphy, Terrence E; Gahbauer, Evelyne A; Leo-Summers, Linda S; Pisani, Margaret A; Gill, Thomas M

2018-05-01

Cognitive impairment is common among older adults, yet little is known about the association of pre-intensive care unit cognitive status with outcomes relevant to older adults maintaining independence after a critical illness. To evaluate whether pre-intensive care unit cognitive status is associated with post-intensive care unit disability, new nursing home admission, and mortality after a critical illness among older adults. In this prospective cohort study, 754 persons aged 70 years or more were monitored from March 1998 to December 2013 with monthly assessments of disability. Cognitive status was assessed every 18 months, using the Mini-Mental State Examination (range, 0-30), with scores classified as 28 or higher (cognitively intact), 24-27 (minimal impairment), and less than 24 (moderate impairment). The primary outcome was disability count (range, 0-13), assessed monthly over 6 months after an intensive care unit stay. The secondary outcomes were incident nursing home admission and time to death after intensive care unit admission. The analytic sample included 391 intensive care unit admissions. The mean age was 83.5 years. The prevalence of moderate impairment, minimal impairment, and intact cognition (the comparison group) was 17.3, 46.2, and 36.5%, respectively. In the multivariable analysis, moderate impairment was associated with nearly a 20% increase in disability over the 6-month follow-up period (adjusted relative risk, 1.19; 95% confidence interval, 1.04-1.36), and minimal impairment was associated with a 16% increase in post-intensive care unit disability (adjusted relative risk, 1.16; 95% confidence interval, 1.02-1.32). Moderate impairment was associated with more than double the likelihood of a new nursing home admission (adjusted odds ratio, 2.37; 95% confidence interval, 1.01-5.55). Survival differed significantly across the three cognitive groups (log-rank P = 0.002), but neither moderate impairment (adjusted hazard ratio, 1.19; 95% confidence interval, 0.65-2.19) nor minimal impairment (adjusted hazard ratio, 1.00; 95% confidence interval, 0.61-1.62) was significantly associated with mortality in the multivariable analysis. Among older adults, any impairment (even minimal) in pre-intensive care unit cognitive status was associated with an increase in post-intensive care unit disability over the 6 months after a critical illness; moderate cognitive impairment doubled the likelihood of a new nursing home admission. Pre-intensive care unit cognitive impairment was not associated with mortality from intensive care unit admission through 6 months of follow-up. Pre-intensive care unit cognitive status may provide prognostic information about the likelihood of older adults maintaining independence after a critical illness.

Pharmacist care plans and documentation of follow-up before the Iowa Pharmaceutical Case Management program.

PubMed

Becker, CoraLynn; Bjornson, Darrel C; Kuhle, Julie W

2004-01-01

To document drug therapy problems and their causes and assess pharmacist follow-up of patients with identified drug therapy problems. Cross-sectional analysis. Iowa. 160 pharmacists who submitted 754 pharmaceutical care plans in an effort to qualify for participation in the Iowa Pharmaceutical Case Management program. Care plans were assessed for drug therapy problems and causes and for documentation of pharmacist follow-up (actual, none, or intent to follow up). Pharmacists documented a wide variety of drug therapy problems and causes, including adverse drug reactions (20.1% of care plans), need for additional drug therapy (18.9%), lack of patient adherence to therapy (16.3%), incorrect medication being prescribed (14.1%), and drug dose too high (10.0%). Pharmacist follow-up with patients was not optimal, with 31% of care plans providing documentation of actual follow-up. Another 42.2% of plans indicated that the pharmacist intended to contact the patient for follow-up but either did not do so or did not record the intervention. No actual follow-up or intent to follow up was recorded in 26.8% of care plans. Pharmacists practicing in independent pharmacies followed up with patients more frequently than those in other settings (36.4% of care plans, compared with 22.7%, 23.2%, and 28.4% for chain, clinic, and franchise pharmacies). Pharmacists were more likely to follow up when the identified problem involved drug safety rather than effectiveness (36.2% versus 28.3% of care plans). Documentation of pharmacist follow-up with patients was less than optimal. In addition to identifying drug therapy problems and causes, pharmacists must complete the care continuum through documentation of patient monitoring and follow-up to transform the philosophy and vision of the pharmaceutical care concept into a practice of pharmacy recognized and rewarded by patients and payers.

A Framework for Comprehensive Health Terminology Systems in the United States

PubMed Central

Chute, Christopher G.; Cohn, Simon P.; Campbell, James R.

1998-01-01

Health care in the United States has become an information-intensive industry, yet electronic health records represent patient data inconsistently for lack of clinical data standards. Classifications that have achieved common acceptance, such as the ICD-9-CM or ICD, aggregate heterogeneous patients into broad categories, which preclude their practical use in decision support, development of refined guidelines, or detailed comparison of patient outcomes or benchmarks. This document proposes a framework for the integration and maturation of clinical terminologies that would have practical applications in patient care, process management, outcome analysis, and decision support. Arising from the two working groups within the standards community—the ANSI (American National Standards Institute) Healthcare Informatics Standards Board Working Group and the Computer-based Patient Records Institute Working Group on Codes and Structures—it outlines policies regarding 1) functional characteristics of practical terminologies, 2) terminology models that can broaden their applications and contribute to their sustainability, 3) maintenance attributes that will enable terminologies to keep pace with rapidly changing health care knowledge and process, and 4) administrative issues that would facilitate their accessibility, adoption, and application to improve the quality and efficiency of American health care. PMID:9824798

Bereaved family member perceptions of quality of end-of-life care in U.S. regions with high and low usage of intensive care unit care.

PubMed

Teno, Joan M; Mor, Vincent; Ward, Nicholas; Roy, Jason; Clarridge, Brian; Wennberg, John E; Fisher, Elliott S

2005-11-01

To compare the quality of end-of-life care of persons dying in regions of differing practice intensity. Mortality follow-back survey. Geographic regions in the highest and lowest deciles of intensive care unit (ICU) use. Bereaved family member or other knowledgeable informants. Unmet needs, concerns, and rating of quality of end-of-life care in five domains (physical comfort and emotional support of the decedent, shared decision-making, treatment of the dying person with respect, providing information and emotional support to family members). Decedents in high- (n=365) and low-intensity (n=413) hospital service areas (HSAs) did not differ in age, sex, education, marital status, leading causes of death, or the degree to which death was expected, but those in the high-intensity ICU HSAs were more likely to be black and to live in nonrural areas. Respondents in high-intensity HSAs were more likely to report that care was of lower quality in each domain, and these differences were statistically significant in three of five domains. Respondents from high-intensity HSAs were more likely to report inadequate emotional support for the decedent (relative risk (RR)=1.2, 95% confidence interval (CI)=1.0-1.4), concerns with shared decision-making (RR=1.8, 95% CI=1.0-2.9), inadequate information about what to expect (RR=1.5, 95% CI=1.3-1.8), and failure to treat the decedent with respect (RR=1.4, 95% CI=1.0-1.9). Overall ratings of the quality of end-of-life care were also significantly lower in high-intensity HSAs. Dying in regions with a higher use of ICU care is not associated with improved perceptions of quality of end-of-life care.

Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care.

PubMed

Cifuentes, Maribel; Davis, Melinda; Fernald, Doug; Gunn, Rose; Dickinson, Perry; Cohen, Deborah J

2015-01-01

This article describes the electronic health record (EHR)-related experiences of practices striving to integrate behavioral health and primary care using tailored, evidenced-based strategies from 2012 to 2014; and the challenges, workarounds and initial health information technology (HIT) solutions that emerged during implementation. This was an observational, cross-case comparative study of 11 diverse practices, including 8 primary care clinics and 3 community mental health centers focused on the implementation of integrated care. Practice characteristics (eg, practice ownership, federal designation, geographic area, provider composition, EHR system, and patient panel characteristics) were collected using a practice information survey and analyzed to report descriptive information. A multidisciplinary team used a grounded theory approach to analyze program documents, field notes from practice observation visits, online diaries, and semistructured interviews. Eight primary care practices used a single EHR and 3 practices used 2 different EHRs, 1 to document behavioral health and 1 to document primary care information. Practices experienced common challenges with their EHRs' capabilities to 1) document and track relevant behavioral health and physical health information, 2) support communication and coordination of care among integrated teams, and 3) exchange information with tablet devices and other EHRs. Practices developed workarounds in response to these challenges: double documentation and duplicate data entry, scanning and transporting documents, reliance on patient or clinician recall for inaccessible EHR information, and use of freestanding tracking systems. As practices gained experience with integration, they began to move beyond workarounds to more permanent HIT solutions ranging in complexity from customized EHR templates, EHR upgrades, and unified EHRs. Integrating behavioral health and primary care further burdens EHRs. Vendors, in cooperation with clinicians, should intentionally design EHR products that support integrated care delivery functions, such as data documentation and reporting to support tracking patients with emotional and behavioral problems over time and settings, integrated teams working from shared care plans, template-driven documentation for common behavioral health conditions such as depression, and improved registry functionality and interoperability. This work will require financial support and cooperative efforts among clinicians, EHR vendors, practice assistance organizations, regulators, standards setters, and workforce educators. © Copyright 2015 by the American Board of Family Medicine.

An Electronic Nursing Patient Care Plan Helps in Clinical Decision Support.

PubMed

Wong, C M; Wu, S Y; Ting, W H; Ho, K H; Tong, L H; Cheung, N T

2015-01-01

Information technology can help to improve health care delivery. The utilisation of informatics principle enhances the quality of nursing practices through improved communication, documentation and efficiency. The Nursing Profession constitutes 34% of the total workforce in the Hong Kong Hospital Authority (HA) and includes 21,000 nurses in 2012. To enhance the quality of care and patient safety in both hospitals and community care setting, it is essential that an integrated electronic decision support system for nurses is designed to track documentation and support care or service including observations, decisions, actions and outcomes throughout the care process at each point-of-care. The Patient Care Plan project was set up to achieve these objectives. The Project adheres to strict documentation information architecture to ensure data sharing is freely available. Preliminary results showed very promising improvement in clinical care.

Development of the Quality of Australian Nursing Documentation in Aged Care (QANDAC) instrument to assess paper-based and electronic resident records.

PubMed

Wang, Ning; Björvell, Catrin; Hailey, David; Yu, Ping

2014-12-01

To develop an Australian nursing documentation in aged care (Quality of Australian Nursing Documentation in Aged Care (QANDAC)) instrument to measure the quality of paper-based and electronic resident records. The instrument was based on the nursing process model and on three attributes of documentation quality identified in a systematic review. The development process involved five phases following approaches to designing criterion-referenced measures. The face and content validities and the inter-rater reliability of the instrument were estimated using a focus group approach and consensus model. The instrument contains 34 questions in three sections: completion of nursing history and assessment, description of care process and meeting the requirements of data entry. Estimates of the validity and inter-rater reliability of the instrument gave satisfactory results. The QANDAC instrument may be a useful audit tool for quality improvement and research in aged care documentation. © 2013 ACOTA.

Mismatch between physicians and family members views on communications about patients with chronic incurable diseases receiving care in critical and intensive care settings in Georgia: a quantitative observational survey.

PubMed

Chikhladze, Nana; Janberidze, Elene; Velijanashvili, Mariam; Chkhartishvili, Nikoloz; Jintcharadze, Memed; Verne, Julia; Kordzaia, Dimitri

2016-07-22

Physicians working in critical and intensive care settings encounter death of chronic incurable patients on a daily basis; however they have scant skills on how to communicate with the patients and their family members. The aim of the present survey is to examine communication of critical and intensive care physicians with patients' family members receiving treatment due to chronic incurable diseases/conditions and to compare the views of families with physicians working in critical and intensive care settings. The survey was conducted in four cities of Georgia (Tbilisi, Kutaisi, Batumi and Telavi) in 2014. Physicians working in critical and intensive care settings and family members were asked to fill in separate questionnaires, covering various aspects of communication including patients' prognosis, ways of death occurrence, treatment plans and religion. Participants ranked their responses on a scale ranging from "0" to "10", where "0" represented "never" and "10"-"always". After data collection, responses were recoded into three categories: 0-3 = never/rarely, 4-7 = somewhat and 8-10 = often/always. Differences were tested using Pearson's chi-square or Fisher's exact test as appropriate. P value of < 0.05 was considered as significant. Sixty-five physicians and 59 patients' family members participated in this cross-sectional study. Majority of their responses was statistically significantly different. Only one quarter (23.7 %) of family members of patients receiving medical aid in critical and intensive care settings were satisfied with the communication level. In contrast, 78.5 % of physicians considered their communication with families as positive (p < 0.0001). The survey revealed the mismatch between the views on communication of critical and intensive care settings physicians and family members of the patients with chronic incurable diseases receiving care in critical and intensive care settings. In order to provide the best care for chronic incurable patients and their family members, physicians working in critical and intensive care settings must have relevant clinical knowledge and ability to provide effective communication. Present results reflect important potential targets for educational interventions including critical and intensive care physicians training through online modules.

Implementation and evaluation of a follow-up programme after intensive care treatment: A practice development project.

PubMed

van Mol, Margo; Ista, Erwin; van Dijk, Monique

2018-05-02

This study aimed to measure the effects of a newly developed follow-up programme on intensive care unit patient quality of care, as perceived by their relatives, and the appropriateness of the programme according to nurses. This before and after implementation study was conducted in a level III intensive care unit for adult patients and related follow-up wards and included 135 intensive care nurses and 105 general ward nurses. The implemented programme included a personalised poster, a revised discharge protocol and follow-up visits on the ward. Eligible relatives of patients who had remained in the intensive care for a minimum of 48 hours were included. Total quality of care and communication were assessed by relatives as high according to the Quality Monitor. Most intensive care nurses evaluated the usefulness of the discharge protocol as positive (71.8% partly/totally agreed) and in accordance with the patients' needs (82.1% partly/totally agreed). Communication and general support as perceived by patients' relatives improved; however, no influence on the total quality of care of the revised discharge protocol was shown. Nurses considered the programme as useful. The intervention might enable nurses to better respond to the instrumental and affective needs of patients and their relatives. Copyright © 2018 Elsevier Ltd. All rights reserved.

Is Postoperative Intensive Care Unit Care Necessary following Cranial Vault Remodeling for Sagittal Synostosis?

PubMed

Wolfswinkel, Erik M; Howell, Lori K; Fahradyan, Artur; Azadgoli, Beina; McComb, J Gordon; Urata, Mark M

2017-12-01

Of U.S. craniofacial and neurosurgeons, 94 percent routinely admit patients to the intensive care unit following cranial vault remodeling for correction of sagittal synostosis. This study aims to examine the outcomes and cost of direct ward admission following primary cranial vault remodeling for sagittal synostosis. An institutional review board-approved retrospective review was undertaken of the records of all patients who underwent primary cranial vault remodeling for isolated sagittal craniosynostosis from 2009 to 2015 at a single pediatric hospital. Patient demographics, perioperative course, and outcomes were recorded. One hundred ten patients met inclusion criteria with absence of other major medical problems. Average age at operation was 6.7 months, with a mean follow-up of 19.8 months. Ninety-eight patients (89 percent) were admitted to a general ward for postoperative care, whereas the remaining 12 (11 percent) were admitted to the intensive care unit for preoperative or perioperative concerns. Among ward-admitted patients, there were four (3.6 percent) minor complications; however, there were no major adverse events, with none necessitating intensive care unit transfers from the ward and no mortalities. Average hospital stay was 3.7 days. The institution's financial difference in cost of intensive care unit stay versus ward bed was $5520 on average per bed per day. Omitting just one intensive care unit postoperative day stay for this patient cohort would reduce projected health care costs by a total of $540,960 for the study period. Despite the common practice of postoperative admission to the intensive care unit following cranial vault remodeling for sagittal craniosynostosis, the authors suggest that postoperative care be considered on an individual basis, with only a small percentage requiring a higher level of care. Therapeutic, III.

[Palliative care in the intensive cardiac care unit: a new competence for the cardiac intensivist].

PubMed

Romanò, Massimo; Bertona, Roberta; Zorzoli, Federica; Villani, Rosvaldo

2017-10-01

Admissions to the intensive care unit at the end of life of patients with chronic non-malignant diseases are increasing. This involves the need for the development of palliative care culture and competence, also in the field of intensive cardiology. Palliative care should be implemented in the treatment of all patients with critical stages of disease, irrespective of prognosis, in order to improve the quality of care at the end of life.This review analyzes in detail the main clinical, ethical and communicational issues to move toward the introduction of basics of palliative care in cardiac intensive care units. It outlines the importance of shared decision-making with the patient and his family, with special attention to withholding/withdrawing of life-sustaining treatments, palliative sedation, main symptom control, patient and family psychological support.

Quality and correlates of medical record documentation in the ambulatory care setting

PubMed Central

Soto, Carlos M; Kleinman, Kenneth P; Simon, Steven R

2002-01-01

Background Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record. Methods We reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians) at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care. Results Among internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 – 2.83) but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 – 0.75). Conclusions Medical record documentation varied depending on the measure, with room for improvement in most domains. A variety of characteristics correlated with medical record documentation, but no pattern emerged. Further study could lead to targeted interventions to improve documentation. PMID:12473161

Preparing your intensive care unit to respond in crisis: considerations for critical care clinicians.

PubMed

Daugherty, Elizabeth L; Rubinson, Lewis

2011-11-01

In recent years, healthcare disaster planning has grown from its early place as an occasional consideration within the manuals of emergency medical services and emergency department managers to a rapidly growing field, which considers continuity of function, surge capability, and process changes across the spectrum of healthcare delivery. A detailed examination of critical care disaster planning was undertaken in 2007 by the Task Force for Mass Critical Care of the American College of Chest Physicians Critical Care Collaborative Initiative. We summarize the Task Force recommendations and available updated information to answer a fundamental question for critical care disaster planners: What is a prepared intensive care unit and how do I ensure my unit's readiness? Database searches and review of relevant published literature. Preparedness is essential for successful response, but because intensive care units face many competing priorities, without defining "preparedness for what," the task can seem overwhelming. Intensive care unit disaster planners should, therefore, along with the entire hospital, participate in a hospital or regionwide planning process to 1) identify critical care response vulnerabilities; and 2) clarify the hazards for which their community is most at risk. The process should inform a comprehensive written preparedness plan targeting the most worrisome scenarios and including specific guidance on 1) optimal use of space, equipment, and staffing for delivery of critical care to significantly increased patient volumes; 2) allocation of resources for provision of essential critical care services under conditions of absolute scarcity; 3) intensive care unit evacuation; and 4) redundant internal communication systems and means for timely data collection. Critical care disaster planners have a complex, challenging task. Experienced planners will agree that no disaster response is perfect, but careful planning will enable the prepared intensive care unit to respond effectively in times of crisis.

Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors.

PubMed

Ward, Nicholas S; Read, Richard; Afessa, Bekele; Kahn, Jeremy M

2012-02-01

Increases in the size and number of American intensive care units have not been accompanied by a comparable increase in the critical care physician workforce, raising concerns that intensivists are becoming overburdened by workload. This is especially concerning in academic intensive care units where attending physicians must couple teaching duties with patient care. We performed an in-person and electronic survey of the membership of the Association of Pulmonary and Critical Care Medicine Program Directors, soliciting information about patient workload, other hospital and medical education duties, and perceptions of the workplace and teaching environment of their intensive care units. Eighty-four out of a total 121 possible responses were received from program directors or their delegates, resulting in a response rate of 69%. The average daily (SD) census (as perceived by the respondents) was 18.8 ± 8.9 patients, and average (SD) maximum service size recalled was 24.1 ± 9.9 patients. Twenty-seven percent reported no policy setting an upper limit for the daily census. Twenty-eight percent of respondents felt the average census was "too many" and 71% felt the maximum size was "too many." The median (interquartile range) patient-to-attending physician ratio was 13 (10-16). When categorized according to this median, respondents from intensive care units with high patient/physician ratios (n = 31) perceived significantly more time constraints, more stress, and difficulties with teaching trainees than respondents with low patient/physician ratios (n = 40). The total number of non-nursing healthcare workers per patient was similar in both groups, suggesting that having more nonattending physician staff does not alleviate perceptions of overwork and stress in the attending physician. Academic intensive care unit physicians that direct fellowship programs frequently perceived being overburdened in the intensive care unit. Understaffing intensive care units with attending physicians may have a negative impact on teaching, patient care, and workforce stability.

Decision making in the neonatal intensive care environment.

PubMed

Rivers, R P

1996-04-01

Consideration as to whether withdrawal of intensive care support might be a more appropriate line of action than to continue with full intensive care has become a part of the life and death decision making process undertaken in neonatal intensive care units. After outlining the moral objectives of delivery of health care, the arguments for taking quality of life and its various components into account during these deliberations are presented. The circumstances in which the appropriateness of continuing care should be considered are highlighted and the care options presented. The crucial importance of allowing time for parents to come to terms with the situation is emphasised as is the need for giving clear guidelines to junior staff over resuscitation issues. Finally, an environment for providing optimal family support during the process of withdrawal is suggested.

Electronic health record interventions at the point of care improve documentation of care processes and decrease orders for genetic tests commonly ordered by nongeneticists.

PubMed

Scheuner, Maren T; Peredo, Jane; Tangney, Kelly; Schoeff, Diane; Sale, Taylor; Lubick-Goldzweig, Caroline; Hamilton, Alison; Hilborne, Lee; Lee, Martin; Mittman, Brian; Yano, Elizabeth M; Lubin, Ira M

2017-01-01

To determine whether electronic health record (EHR) tools improve documentation of pre- and postanalytic care processes for genetic tests ordered by nongeneticists. We conducted a nonrandomized, controlled, pre-/postintervention study of EHR point-of-care tools (informational messages and template report) for three genetic tests. Chart review assessed documentation of genetic testing processes of care, with points assigned for each documented item. Multiple linear and logistic regressions assessed factors associated with documentation. Preimplementation, there were no significant site differences (P > 0.05). Postimplementation, mean documentation scores increased (5.9 (2.1) vs. 5.0 (2.2); P = 0.0001) and records with clinically meaningful documentation increased (score >5: 59 vs. 47%; P = 0.02) at the intervention versus the control site. Pre- and postimplementation, a score >5 was positively associated with abnormal test results (OR = 4.0; 95% CI: 1.8-9.2) and trainee provider (OR = 2.3; 95% CI: 1.2-4.6). Postimplementation, a score >5 was also positively associated with intervention site (OR = 2.3; 95% CI: 1.1-5.1) and specialty clinic (OR = 2.0; 95% CI: 1.1-3.6). There were also significantly fewer tests ordered after implementation (264/100,000 vs. 204/100,000; P = 0.03), with no significant change at the control site (280/100,000 vs. 257/100,000; P = 0.50). EHR point-of-care tools improved documentation of genetic testing processes and decreased utilization of genetic tests commonly ordered by nongeneticists.Genet Med 19 1, 112-120.

Cephalopod biology and care, a COST FA1301 (CephsInAction) training school: anaesthesia and scientific procedures.

PubMed

Lopes, Vanessa M; Sampaio, Eduardo; Roumbedakis, Katina; Tanaka, Nobuaki K; Carulla, Lucía; Gambús, Guillermo; Woo, Theodosia; Martins, Catarina P P; Penicaud, Virginie; Gibbings, Colette; Eberle, Jessica; Tedesco, Perla; Fernández, Isabel; Rodríguez-González, Tania; Imperadore, Pamela; Ponte, Giovanna; Fiorito, Graziano

2017-09-01

Cephalopods are the sole invertebrates included in the list of regulated species following the Directive 2010/63/EU. According to the Directive, achieving competence through adequate training is a requisite for people having a role in the different functions (article 23) as such carrying out procedures on animals, designing procedures and projects, taking care of animals, killing animals. Cephalopod Biology and Care Training Program is specifically designed to comply with the requirements of the "working document on the development of a common education and training framework to fulfil the requirements under the Directive 2010/63/EU". The training event occurred at the ICM-CSIC in Barcelona (Spain) where people coming from Europe, America and Asia were instructed on how to cope with regulations for the use of cephalopod molluscs for scientific purposes. The training encompasses discussion on the guidelines for the use and care of animals and their welfare with particular reference to procedures that may be of interest for neuroscience. Intensive discussion has been carried out during the training sessions with focus on behavioural studies and paradigms, welfare assessment, levels of severity of scientific procedures, animal care, handling, transport, individual identification and marking, substance administration, anaesthesia, analgesia and humane killing.

An automated knowledge-based textual summarization system for longitudinal, multivariate clinical data.

PubMed

Goldstein, Ayelet; Shahar, Yuval

2016-06-01

Design and implement an intelligent free-text summarization system: The system's input includes large numbers of longitudinal, multivariate, numeric and symbolic clinical raw data, collected over varying periods of time, and in different complex contexts, and a suitable medical knowledge base. The system then automatically generates a textual summary of the data. We aim to prove the feasibility of implementing such a system, and to demonstrate its potential benefits for clinicians and for enhancement of quality of care. We have designed a new, domain-independent, knowledge-based system, the CliniText system, for automated summarization in free text of longitudinal medical records of any duration, in any context. The system is composed of six components: (1) A temporal abstraction module generates all possible abstractions from the patient's raw data using a temporal-abstraction knowledge base; (2) The abductive reasoning module infers abstractions or events from the data, which were not explicitly included in the database; (3) The pruning module filters out raw or abstract data based on predefined heuristics; (4) The document structuring module organizes the remaining raw or abstract data, according to the desired format; (5) The microplanning module, groups the raw or abstract data and creates referring expressions; (6) The surface realization module, generates the text, and applies the grammar rules of the chosen language. We have performed an initial technical evaluation of the system in the cardiac intensive-care and diabetes domains. We also summarize the results of a more detailed evaluation study that we have performed in the intensive-care domain that assessed the completeness, correctness, and overall quality of the system's generated text, and its potential benefits to clinical decision making. We assessed these measures for 31 letters originally composed by clinicians, and for the same letters when generated by the CliniText system. We have successfully implemented all of the components of the CliniText system in software. We have also been able to create a comprehensive temporal-abstraction knowledge base to support its functionality, mostly in the intensive-care domain. The initial technical evaluation of the system in the cardiac intensive-care and diabetes domains has shown great promise, proving the feasibility of constructing and operating such systems. The detailed results of the evaluation in the intensive-care domain are out of scope of the current paper, and we refer the reader to a more detailed source. In all of the letters composed by clinicians, there were at least two important items per letter missed that were included by the CliniText system. The clinicians' letters got a significantly better grade in three out of four measured quality parameters, as judged by an expert; however, the variance in the quality was much higher in the clinicians' letters. In addition, three clinicians answered questions based on the discharge letter 40% faster, and answered four out of the five questions equally well or significantly better, when using the CliniText-generated letters, than when using the clinician-composed letters. Constructing a working system for automated summarization in free text of large numbers of varying periods of multivariate longitudinal clinical data is feasible. So is the construction of a large knowledge base, designed to support such a system, in a complex clinical domain, such as the intensive-care domain. The integration of the quality and functionality results suggests that the optimal discharge letter should exploit both human and machine, possibly by creating a machine-generated draft that will be polished by a human clinician. Copyright © 2016 Elsevier Inc. All rights reserved.

Audit of availability and distribution of paediatric cardiology services and facilities in Nigeria

PubMed Central

Ekure, Ekanem N; Sadoh, Wilson E; Bode-Thomas, Fidelia; Yilgwan, Christopher S; Orogade, Adeola A; Animasahun, Adeola B; Ogunkunle, Oluwatoyin O; Omokhodion, Samuel I; Babaniyi, Iretiola; Anah, Maxwell U; Otaigbe, Barbara E; Olowu, Adebiyi; Okpokowuruk, Frances; Maduka, Ogechi C; Onakpoya, Uvie U; Adiele, Daberechi K; Sani, Usman. M; Asani, Mustapha; Daniels, Queennette; Uzodimma, Chinyere C; Duru, Chika O; Abdulkadir, Mohammad B; Afolabi, Joseph K; Okeniyi, John A

2017-01-01

Summary Background Paediatric cardiac services in Nigeria have been perceived to be inadequate but no formal documentation of availability and distribution of facilities and services has been done. Objective: To evaluate and document the currently available paediatric cardiac services in Nigeria. Methods In this questionnaire-based, cross-sectional descriptive study, an audit was undertaken from January 2010 to December 2014, of the personnel and infrastructure, with their distributions according to geopolitical zones of Nigeria. Results Forty-eight centres participated in the study, with 33 paediatric cardiologists and 31 cardiac surgeons. Echocardiography, electrocardiography and pulse oximetry were available in 45 (93.8%) centres while paediatric intensive care units were in 23 (47.9%). Open-heart surgery was performed in six (12.5%) centres. South-West zone had the majority of centres (20; 41.7%). Conclusions Available paediatric cardiac services in Nigeria are grossly inadequate and poorly distributed. Efforts should be intensified to upgrade existing facilities, establish new and functional centres, and train personnel. PMID:27701490

Audit of availability and distribution of paediatric cardiology services and facilities in Nigeria.

PubMed

Ekure, Ekanem N; Sadoh, Wilson E; Bode-Thomas, Fidelia; Orogade, Adeola A; Animasahun, Adeola B; Ogunkunle, Oluwatoyin O; Babaniyi, Iretiola; Anah, Maxwell U; Otaigbe, Barbara E; Olowu, Adebiyi; Okpokowuruk, Frances; Omokhodion, Samuel I; Maduka, Ogechi C; Onakpoya, Uvie U; Adiele, Daberechi K; Sani, Usman M; Asani, Mustapha; Yilgwan, Christopher S; Daniels, Queennette; Uzodimma, Chinyere C; Duru, Chika O; Abdulkadir, Mohammad B; Afolabi, Joseph K; Okeniyi, John A

Paediatric cardiac services in Nigeria have been perceived to be inadequate but no formal documentation of availability and distribution of facilities and services has been done. To evaluate and document the currently available paediatric cardiac services in Nigeria. In this questionnaire-based, cross-sectional descriptive study, an audit was undertaken from January 2010 to December 2014, of the personnel and infrastructure, with their distributions according to geopolitical zones of Nigeria. Forty-eight centres participated in the study, with 33 paediatric cardiologists and 31 cardiac surgeons. Echocardiography, electrocardiography and pulse oximetry were available in 45 (93.8%) centres while paediatric intensive care units were in 23 (47.9%). Open-heart surgery was performed in six (12.5%) centres. South-West zone had the majority of centres (20; 41.7%). Available paediatric cardiac services in Nigeria are grossly inadequate and poorly distributed. Efforts should be intensified to upgrade existing facilities, establish new and functional centres, and train personnel.

Basic Competence of Intensive Care Unit Nurses: Cross-Sectional Survey Study

PubMed Central

Lakanmaa, Riitta-Liisa; Suominen, Tarja; Ritmala-Castrén, Marita; Vahlberg, Tero; Leino-Kilpi, Helena

2015-01-01

Critical care patients benefit from the attention of nursing personnel with a high competence level. The aim of the study was to describe and evaluate the self-assessed basic competence of intensive care unit nurses and related factors. A cross-sectional survey design was used. A basic competence scale (Intensive and Critical Care Nursing Competence Scale version 1, Likert scale 1–5, 1 = poor and 5 = excellent) was employed among Finnish intensive care unit nurses (n = 431). Intensive care unit nurses' self-assessed basic competence was good (mean 4.19, SD 0.40). The attitude and value base of basic competence was excellent whereas experience base was the poorest compared to the knowledge base and skill base of intensive and critical care nursing. The strongest factor explaining nurses' basic competence was their experience of autonomy in nursing care (F value 60.85, β 0.11, SE 0.01, and P ≤ 0.0001). Clinical competence was self-rated as good. Nurses gave their highest competence self-ratings for ICU patient care according to the principles of nursing care. The ICU nurses also self-rated their professional competence as good. Collaboration was self-rated as the best competence. In basic and continuing education and professional self-development discussions it is meaningful to consider and find solutions for how to improve nurses' experienced autonomy in nursing. PMID:26557676

Information Technology in Critical Care: Review of Monitoring and Data Acquisition Systems for Patient Care and Research

PubMed Central

De Georgia, Michael A.; Kaffashi, Farhad; Jacono, Frank J.; Loparo, Kenneth A.

2015-01-01

There is a broad consensus that 21st century health care will require intensive use of information technology to acquire and analyze data and then manage and disseminate information extracted from the data. No area is more data intensive than the intensive care unit. While there have been major improvements in intensive care monitoring, the medical industry, for the most part, has not incorporated many of the advances in computer science, biomedical engineering, signal processing, and mathematics that many other industries have embraced. Acquiring, synchronizing, integrating, and analyzing patient data remain frustratingly difficult because of incompatibilities among monitoring equipment, proprietary limitations from industry, and the absence of standard data formatting. In this paper, we will review the history of computers in the intensive care unit along with commonly used monitoring and data acquisition systems, both those commercially available and those being developed for research purposes. PMID:25734185

Information technology in critical care: review of monitoring and data acquisition systems for patient care and research.

PubMed

De Georgia, Michael A; Kaffashi, Farhad; Jacono, Frank J; Loparo, Kenneth A

2015-01-01

There is a broad consensus that 21st century health care will require intensive use of information technology to acquire and analyze data and then manage and disseminate information extracted from the data. No area is more data intensive than the intensive care unit. While there have been major improvements in intensive care monitoring, the medical industry, for the most part, has not incorporated many of the advances in computer science, biomedical engineering, signal processing, and mathematics that many other industries have embraced. Acquiring, synchronizing, integrating, and analyzing patient data remain frustratingly difficult because of incompatibilities among monitoring equipment, proprietary limitations from industry, and the absence of standard data formatting. In this paper, we will review the history of computers in the intensive care unit along with commonly used monitoring and data acquisition systems, both those commercially available and those being developed for research purposes.

Intensive Care Management of Patients with Cirrhosis.

PubMed

Olson, Jody C

2018-06-01

Cirrhosis is a major worldwide health problem which results in a high level of morbidity and mortality. Patients with cirrhosis who require intensive care support have high mortality rates of near 50%. The goal of this review is to address the management of common complications of cirrhosis in the ICU. Recent epidemiological studies have shown an increase in hospitalizations due to advanced liver disease with an associated increase in intensive care utilization. Given an increasing burden on the healthcare system, it is imperative that we strive to improve our management cirrhotic patients in the intensive care unit. Large studies evaluating the management of patients in the intensive care setting are lacking. To date, most recommendations are based on extrapolation of data from studies in cirrhosis outside of the ICU or by applying general critical care principles which may or may not be appropriate for the critically ill cirrhotic patient. Future research is required to answer important management questions.

Neonatal Intensive Care Unit Nurses Working in an Open Ward: Stress and Work Satisfaction.

PubMed

Lavoie-Tremblay, Mélanie; Feeley, Nancy; Lavigne, Geneviève L; Genest, Christine; Robins, Stéphanie; Fréchette, Julie

2016-01-01

There is some research on the impact of open-ward unit design on the health of babies and the stress experienced by parents and nurses in neonatal intensive care units. However, few studies have explored the factors associated with nurse stress and work satisfaction among nurses practicing in open-ward neonatal intensive care units. The purpose of this study was to examine what factors are associated with nurse stress and work satisfaction among nurses practicing in an open-ward neonatal intensive care unit. A cross-sectional correlational design was used in this study. Participants were nurses employed in a 34-bed open-ward neonatal intensive care unit in a major university-affiliated hospital in Montréal, Quebec, Canada. A total of 94 nurses were eligible, and 86 completed questionnaires (91% response rate). Descriptive statistics were computed to describe the participants' characteristics. To identify factors associated with nurse stress and work satisfaction, correlational analysis and multiple regression analyses were performed with the Nurse Stress Scale and the Global Work Satisfaction scores as the dependent variables. Different factors predict neonatal intensive care unit nurses' stress and job satisfaction, including support, family-centered care, performance obstacles, work schedule, education, and employment status. In order to provide neonatal intensive care units nurses with a supportive environment, managers can provide direct social support to nurses and influence the culture around teamwork.

Preventive Services Use among African American and Latino Adult Caregivers in South Los Angeles

PubMed Central

Mendez-Luck, Carolyn A.; Walker, Kara Odom; Luck, Jeff

2016-01-01

Background The burden of informal caregiving is significant and well-documented, yet the evidence is mixed as to whether being a caregiver presents an additional barrier to receiving recommended preventive care. Objectives To determine whether (1) caregivers compared to non-caregivers were less likely to receive preventive health services; and (2) higher intensity caregivers were less likely to receive preventive health services than lower intensity caregivers. Research Design, Subjects, and Measures Data were from a telephone survey of Latino and African American adults 50 years or older in South Los Angeles (n=702). Outcomes were flu vaccination, pneumococcal vaccination, and colorectal cancer screening. Logistic regression models adjusted for predisposing, enabling, and need factors according to the Andersen Model of Access to Health Care for Low-Income Populations. Results Caregiver type (e.g., adult child, non-related) was associated with varying odds of receiving a preventive service. Caregivers had lower odds than non-caregivers of receiving preventive services although odds of receiving a flu vaccination improved slightly for caregivers of persons with memory loss compared to other caregivers. More weekly caregiving hours was associated with higher odds of receiving flu vaccination (AOR 1.1, 95% CI=1.0, 1.1) or colorectal cancer screening (AOR 1.1, 95% CI=1.0, 1.1). Caregivers and non-caregivers age 65 and older or with chronic conditions were more likely to receive vaccinations. Conclusions Preventive service use was influenced by characteristics of the caregiving situation. An opportunity may exist to leverage care recipients’ ongoing contact with health care providers to increase caregivers’ own access to preventive services. PMID:27414461

In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units.

PubMed

Parshuram, Christopher S; Kirpalani, Haresh; Mehta, Sangeeta; Granton, John; Cook, Deborah

2006-06-01

Physician staffing is an important determinant of patient outcomes following intensive care unit (ICU) admission. We conducted a national survey of in-house after-hours physician staffing in Canadian ICUs. : Cross-sectional survey. Canadian adult and pediatric ICUs. ICU directors. ICU directors of Canadian adult and pediatric ICUs were surveyed to describe overnight staffing by interns, residents, critical care medicine trainees, clinical assistants, and ICU physicians in their ICUs. Data were collected regarding hospital and ICU demographics and ICU staffing. For ICUs with in-house overnight physicians, we documented physician experience, shift duration, and clinical responsibilities outside the ICU. We identified 98 Canadian ICU directors, of whom 88 (90%) responded. Dedicated in-house physician coverage overnight was reported in 53 (60%) ICUs, including 13 (15%) in which ICU staff physicians stayed in-house overnight. Compared with ICUs without in-house physicians, those with in-house physicians had more ICU beds (15 vs. 8.5, p=.0001) and fewer ICU staff physicians (5 vs. 7, p=.03). For the 271 physicians who provide overnight staffing, the median level of postgraduate experience was 3 yrs (range, <1 yr, >10 yrs); 129 (48%) had <3 months of ICU experience. Most shifts (83%) were >20 hrs long. In-house overnight physician staffing in Canadian ICUs varies widely. Only a minority of ICUs comply with the 2003 Society of Critical Care Medicine guidelines for adult ICUs recommending continuous in-house staffing by ICU staff physicians. The duration of most ICU shifts raises concern about workload-associated fatigue and medical error. The impact of current nighttime staffing requires further evaluation with respect to patient outcomes.

[Electronic medical records in Bosnia-Herzegovina. The electronic card--the medical record of the future in Boznia-Herzegovina].

PubMed

Masić, I; Pandza, H; Ridanović, Z; Dover, M

1997-01-01

The biggest problem in organisation of the effective and rational health care of good quality in Bosnia quality and Herzegovina is a functional and updated Health Information System. In this system, important role play Health Statistic System in which documentation and evidence are very important segment. Developed countries proceeded from the manual and semiautomatic method of medical data processing and system management to the new methods of entering, storage, transfer, searching and protection of data using electronic equipment. Recently, the competition between manufacturers of the Smart Card and Laser Card is reality. Also scientific and professional debate exists about the standard card for storage of medical information in Health Care System. First option is supported by West European countries that developing Smart Card called Eurocard and second by USA and Far East countries. Because the Health Care System and other segments of Society of Bosnia and Herzegovina innovate intensively similar systems, the authors of this article intend to open discussion, and to show advantages and failures of each technological medium.

The neonatal nurses' view of their role in emotional support of parents and its complexities.

PubMed

Turner, Melanie; Chur-Hansen, Anna; Winefield, Helen

2014-11-01

To explore the nurses' views of their role both in the neonatal intensive care unit and in the provision of interacting with, and emotionally supporting, families. The neonatal intensive care nurse has a large and complex clinical role and also a role of emotional supporter for parents in the neonatal intensive care unit. Identifying components of their role and recognising the elements within the nursery that obstruct or encourage this role can allow for modification of nurse education and peer support. Qualitative study based on semistructured interviews. Nine neonatal nurses from a single neonatal intensive care unit were interviewed and the data analysed thematically using NVIVO version 10. Participants viewed their role as an enjoyable yet difficult one, requiring seniority, training and experience. They provided support to parents by communicating, listening, providing individualised support and by encouraging parental involvement with their baby. Constructive elements that contributed to the provision of support included a positive neonatal intensive care unit environment and providing a parent support group. More obstructive elements were a lack of physical neonatal intensive care unit space, little time available for nurse-to-parent conversation and language and cultural barriers between nurses and parents. The role of the neonatal nurse in providing emotional support is complex and requires a high level of ongoing support and education for staff, and minimisation of physical and staff-related obstructions. The modern neonatal intensive care unit offers complex medical and nursing services and with this care comes higher needs from both babies and their parents. Neonatal intensive care unit nurses should be supported in their roles by having peer support available in the neonatal intensive care unit and education and training in emotional support and counselling skills. The nursing staff also require a comfortable and practical physical working space in which to assist parents to be with their baby. © 2014 John Wiley & Sons Ltd.

Delirium monitoring and patient outcomes in a general intensive care unit.

PubMed

Andrews, Lois; Silva, Susan G; Kaplan, Susan; Zimbro, Kathie

2015-01-01

Use of an evidence-based tool for routine assessment for delirium by bedside nurses in the intensive care unit is recommended. However, little is known about patient outcomes after implementation of such a tool. To evaluate the implementation and effects of the Confusion Assessment Method for the Intensive Care Unit as a bedside assessment for delirium in a general intensive care unit in a tertiary care hospital. Charts of patients admitted to the unit during a 3-month period before implementation of the assessment tool and 1 year after implementation were reviewed retrospectively. Patient outcomes were incidence of delirium diagnosis, duration of mechanical ventilation, length of stay in the intensive care unit, and time spent in restraints. The 2 groups of patients did not differ in demographics, clinical characteristics, or predisposing factors. The groups also did not differ significantly in delirium diagnosis, duration of mechanical ventilation, length of stay in the intensive care unit, or time spent in restraints. Barriers to use of the tool included nurses' lack of confidence in performing the assessment, concerns about use of the tool in patients receiving mechanical ventilation, and lack of interdisciplinary response to findings obtained with the tool. No change in patient outcomes or diagnosis of delirium occurred 1 year after implementation of the Confusion Assessment Method for the Intensive Care Unit. Lessons learned and barriers to adoption and use, however, were identified. ©2015 American Association of Critical-Care Nurses.

Nurses' knowledge and barriers regarding pain management in intensive care units.

PubMed

Wang, Hsiang-Ling; Tsai, Yun-Fang

2010-11-01

To explore nurses' knowledge and barriers regarding pain management in intensive care units. Pain is a common and treatable condition among intensive care patients. Quality care of these patients depends on the pain knowledge and pain management skills of critical care nurses. However, no single study has explored these nurses' knowledge of and perceived barriers to pain management in Taiwan. A cross-sectional study. Intensive care unit nurses (n = 370) were recruited from 16 hospitals chosen by stratified sampling across Taipei County in Taiwan. Data were collected on nurses' knowledge of pain management using the Nurses' Knowledge and Attitudes Survey-Taiwanese version, on perceived barriers to pain management using a researcher-developed scale and on background information. The overall average correct response rate for the knowledge scale was 53.4%, indicating poor knowledge of pain management. The top barrier to managing pain identified by these nurses was 'giving proper pain prescription needs doctor's approval; can't depend on me'. Knowledge of pain management was significantly and negatively related to perceived barriers to pain management. In addition, scores for knowledge and perceived barriers differed significantly by specific intensive care unit. Knowledge also differed significantly by nurses' education level, clinical competence level (nursing ladder) and hospital accreditation category. Our results indicate an urgent need to strengthen pain education by including case analysis for intensive care nurses in Taiwan. Pain education should target knowledge deficits and barriers to changing pain management approaches for Taiwanese nurses in intensive care units. © 2010 Blackwell Publishing Ltd.

Managing Home Health Care (For Parents)

MedlinePlus

... Videos for Educators Search English Español Managing Home Health Care KidsHealth / For Parents / Managing Home Health Care What's ... español La atención médica en el hogar Intensive Health Care at Home Kids can need intensive health care ...

A "Neurological Emergency Trolley" reduces turnaround time for high-risk medications in a general intensive care unit.

PubMed

Ajzenberg, Henry; Newman, Paula; Harris, Gail-Anne; Cranston, Marnie; Boyd, J Gordon

2018-02-01

To reduce medication turnaround times during neurological emergencies, a multidisciplinary team developed a neurological emergency crash trolley in our intensive care unit. This trolley includes phenytoin, hypertonic saline and mannitol, as well as other equipment. The aim of this study was to assess whether the cart reduced turnaround times for these medications. In this retrospective cohort study, medication delivery times for two year epochs before and after its implementation were compared. Eligible patients were identified from our intensive care unit screening log. Adults who required emergent use of phenytoin, hypertonic saline or mannitol while in the intensive care unit were included. Groups were compared with nonparametric analyses. 33-bed general medical-surgical intensive care unit in an academic teaching hospital. Time to medication administration. In the pre-intervention group, there were 43 patients with 66 events. In the post-intervention group, there were 45 patients with 80 events. The median medication turnaround time was significantly reduced after implementation of the neurological emergency trolley (25 vs. 10minutes, p=0.003). There was no statistically significant difference in intensive care or 30-day survival between the two cohorts. The implementation of a novel neurological emergency crash trolley in our intensive care unit reduced medication turnaround times. Copyright © 2017 Elsevier Ltd. All rights reserved.

A Comparison of Costs Between Medical and Surgical Patients in an Academic Pediatric Intensive Care Unit.

PubMed

Hsu, Benson S; Brazelton, Thomas B

2015-12-01

To estimate the impact of patient type on costs incurred during a pediatric intensive care unit (PICU) hospitalization. Retrospective cohort study at an academic PICU located in the United States that examined 850 patients admitted to the PICU from January 1 to December 31, 2009. Forty-eight patients were excluded due to lack of financial data. Primary service was defined by the attending physician of record. Outcome measures were total and daily pediatric intensive care costs (2009 US dollars). Of 802 patients in the sample, there were 361 medical and 441 surgical patients. Comparing medical to surgical patients, severity of illness as defined by Pediatric Risk of Mortality (PRISM) III scores was 4.53 vs 2.08 (P < 0.001), length of stay was 7.37 vs 5.00 days (P < 0.001), total pediatric intensive care hospital costs were $34,786 vs $30,598 (P < 0.001), and mean daily pediatric intensive care hospital costs were $3985 vs $6616 (P < 0.001). Medical patients had higher severity of illness and length of stay resulting in higher total pediatric intensive care costs when compared to surgical patients. Interestingly, when accounting the length of stay, surgical patients had higher daily pediatric intensive care costs despite lower severity of illness.

[Nurses' perception, experience and knowledge of palliative care in intensive care units].

PubMed

Piedrafita-Susín, A B; Yoldi-Arzoz, E; Sánchez-Fernández, M; Zuazua-Ros, E; Vázquez-Calatayud, M

2015-01-01

Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients. To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients. A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed. Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses. This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making. Copyright © 2014 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

Religious Coping and Behavioral Disengagement: Opposing Influences on Advance Care Planning and Receipt of Intensive Care Near Death

PubMed Central

Maciejewski, Paul K.; Phelps, Andrea C.; Kacel, Elizabeth L.; Balboni, Tracy A.; Balboni, Michael; Wright, Alexi A.; Pirl, William; Prigerson, Holly G.

2011-01-01

Objective This study examines the relationships between methods of coping with advanced cancer, completion of advance care directives, and receipt of intensive, life-prolonging care near death. Methods The analysis is based on a sample of 345 patients interviewed between January 1, 2003, and August 31, 2007, and followed until death as part of the Coping with Cancer Study, an NCI/NIMH-funded, multi-site, prospective, longitudinal, cohort study of patients with advanced cancer. The Brief COPE was used to assess active coping, use of emotional-support, and behavioral disengagement. The Brief RCOPE was used to assess positive and negative religious coping. The main outcome was intensive, life-prolonging care near death, defined as receipt of ventilation or resuscitation in the last week of life. Results Positive religious coping was associated with lower rates of having a living will (AOR=0.39, p=0.003) and predicted higher rates of intensive, life-prolonging care near death (AOR, 5.43; p<0.001), adjusting for other coping methods and potential socio-demographic and health status confounds. Behavioral disengagement was associated with higher rates of DNR order completion (AOR, 2.78; p=0.003) and predicted lower rates of intensive life-prolonging care near death (AOR, 0.20; p=0.036). Not having a living will partially mediated the influence of positive religious coping on receipt of intensive, life-prolonging care near death. Conclusion Positive religious coping and behavioral disengagement are important determinants of completion of advance care directives and receipt of intensive, life-prolonging care near death. PMID:21449037

Evaluation of the effects of implementing an electronic early warning score system: protocol for a stepped wedge study.

PubMed

Bonnici, Timothy; Gerry, Stephen; Wong, David; Knight, Julia; Watkinson, Peter

2016-02-09

An Early Warning Score is a clinical risk score based upon vital signs intended to aid recognition of patients in need of urgent medical attention. The use of an escalation of care policy based upon an Early Warning Score is mandated as the standard of practice in British hospitals. Electronic systems for recording vital sign observations and Early Warning Score calculation offer theoretical benefits over paper-based systems. However, the evidence for their clinical benefit is limited. Previous studies have shown inconsistent results. The majority have employed a "before and after" study design, which may be strongly confounded by simultaneously occurring events. This study aims to examine how the implementation of an electronic early warning score system, System for Notification and Documentation (SEND), affects the recognition of clinical deterioration occurring in hospitalised adult patients. This study is a non-randomised stepped wedge evaluation carried out across the four hospitals of the Oxford University Hospitals NHS Trust, comparing charting on paper and charting using SEND. We assume that more frequent monitoring of acutely ill patients is associated with better recognition of patient deterioration. The primary outcome measure is the time between a patient's first observations set with an Early Warning Score above the alerting threshold and their subsequent set of observations. Secondary outcome measures are in-hospital mortality, cardiac arrest and Intensive Care admission rates, hospital length of stay and system usability measured using the System Usability Scale. We will also measure Intensive Care length of stay, Intensive Care mortality, Acute Physiology and Chronic Health Evaluation (APACHE) II acute physiology score on admission, to examine whether the introduction of SEND has any effect on Intensive Care-related outcomes. The development of this protocol has been informed by guidance from the Agency for Healthcare Research and Quality (AHRQ) Health Information Technology Evaluation Toolkit and Delone and McLeans's Model of Information System Success. Our chosen trial design, a stepped wedge study, is well suited to the study of a phased roll out. The choice of primary endpoint is challenging. We have selected the time from the first triggering observation set to the subsequent observation set. This has the benefit of being easy to measure on both paper and electronic charting and having a straightforward interpretation. We have collected qualitative measures of system quality via a user questionnaire and organisational descriptors to help readers understand the context in which SEND has been implemented.

Implementing Family Meetings Into a Respiratory Care Unit: A Care and Communication Quality Improvement Project.

PubMed

Loeslie, Vicki; Abcejo, Ma Sunnimpha; Anderson, Claudia; Leibenguth, Emily; Mielke, Cathy; Rabatin, Jeffrey

Substantial evidence in critical care literature identifies a lack of quality and quantity of communication between patients, families, and clinicians while in the intensive care unit. Barriers include time, multiple caregivers, communication skills, culture, language, stress, and optimal meeting space. For patients who are chronically critically ill, the need for a structured method of communication is paramount for discussion of goals of care. The objective of this quality improvement project was to identify barriers to communication, then develop, implement, and evaluate a process for semistructured family meetings in a 9-bed respiratory care unit. Using set dates and times, family meetings were offered to patients and families admitted to the respiratory care unit. Multiple avenues of communication were utilized to facilitate attendance. Utilizing evidence-based family meeting literature, a guide for family meetings was developed. Templates were developed for documentation of the family meeting in the electronic medical record. Multiple communication barriers were identified. Frequency of family meeting occurrence rose from 31% to 88%. Staff satisfaction with meeting frequency, meeting length, and discussion of congruent goals of care between patient/family and health care providers improved. Patient/family satisfaction with consistency of message between team members; understanding of medications, tests, and dismissal plan; and efficacy to address their concerns with the medical team improved. This quality improvement project was implemented to address the communication gap in the care of complex patients who require prolonged hospitalizations. By identifying this need, engaging stakeholders, and developing a family meeting plan to meet to address these needs, communication between all members of the patient's care team has improved.

Leveraging Text Content for Management of Construction Project Documents

ERIC Educational Resources Information Center

Alqady, Mohammed

2012-01-01

The construction industry is a knowledge intensive industry. Thousands of documents are generated by construction projects. Documents, as information carriers, must be managed effectively to ensure successful project management. The fact that a single project can produce thousands of documents and that a lot of the documents are generated in a…

Implementation and evaluation of a nursing home fall management program.

PubMed

Rask, Kimberly; Parmelee, Patricia A; Taylor, Jo A; Green, Diane; Brown, Holly; Hawley, Jonathan; Schild, Laura; Strothers, Harry S; Ouslander, Joseph G

2007-03-01

To evaluate the feasibility and effectiveness of a falls management program (FMP) for nursing homes (NHs). A quality improvement project with data collection throughout FMP implementation. NHs in Georgia owned and operated by a single nonprofit organization. All residents of participating NHs. A convenience sample of 19 NHs implemented the FMP. The FMP is a multifaceted quality improvement and culture change intervention. Key components included organizational leadership buy-in and support, a designated facility-based falls coordinator and interdisciplinary team, intensive education and training, and ongoing consultation and oversight by advanced practice nurses with expertise in falls management. Process-of-care documentation using a detailed 24-item audit tool and fall and physical restraint use rates derived from quality improvement software currently used in all Georgia NHs (MyInnerView). Care process documentation related to the assessment and management of fall risk improved significantly during implementation of the FMP. Restraint use decreased substantially during the project period, from 7.9% to 4.4% in the intervention NHs (a relative reduction of 44%), and decreased in the nonintervention NHs from 7.0% to 4.9% (a relative reduction of 30%). Fall rates remained stable in the intervention NHs (17.3 falls/100 residents per month at start and 16.4 falls/100 residents per month at end), whereas fall rates increased 26% in the NHs not implementing the FMP (from 15.0 falls/100 residents/per month to 18.9 falls/100 residents per month). Implementation was associated with significantly improved care process documentation and a stable fall rate during a period of substantial reduction in the use of physical restraints. In contrast, fall rates increased in NHs owned by the same organization that did not implement the FMP. The FMP may be a helpful tool for NHs to manage fall risk while attempting to reduce physical restraint use in response to the Centers for Medicare and Medicaid Services quality initiatives.

Operationalizing the Measuring What Matters Spirituality Quality Metric in a Population of Hospitalized, Critically Ill Patients and Their Family Members.

PubMed

Aslakson, Rebecca A; Kweku, Josephine; Kinnison, Malonnie; Singh, Sarabdeep; Crowe, Thomas Y

2017-03-01

Measuring What Matters (MWM) quality indicators support measurement of the percentage of patients who have spiritual discussions, if desired. The objective of this study was to 1) determine the ease of, and barriers to, prospectively collecting MWM spirituality quality measure data and 2) further explore the importance of spirituality in a seriously ill, hospitalized population of critically ill patients and their family members. Electronic medical record (EMR) review and cross-sectional survey of intensive care unit (ICU) patients and their family members from October to December 2015. Participants were in four adult ICUs totaling 68 beds at a single academic, urban, tertiary care center which has ICU-assigned chaplains and an in-house, 24-hour, on-call chaplain. All patients had a "Spiritual Risk Screen" which included two questions identifying patient religion and whether a chaplain visit was desired. Approximately 2/3 of ICU patients were eligible, and there were 144 respondents (50% female; 57% patient and 43% family member), with the majority being Caucasian or African American (68% and 21%, respectively). Common religious identifications were Christian or no faith tradition (76% and 11%, respectively). Approximately half of patients had an EMR chaplain note although it did not document presence of a "spiritual discussion." No study patients received palliative care consultation. A majority (85%) noted that spirituality was "important to them" and that prevalence remained high across respondent age, race, faith tradition, or admitting ICU. Operationalizing the MWM spirituality quality indicator was challenging as elements of a "spiritual screening" or documentation of a "spiritual discussion" were not clearly documented in the EMR. The high prevalence of spirituality among respondents validates the importance of spirituality as a potential quality metric. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Using mobile devices for inpatient rounding and handoffs: an innovative application developed and rapidly adopted by clinicians in a pediatric hospital.

PubMed

Motulsky, Aude; Wong, Jenna; Cordeau, Jean-Pierre; Pomalaza, Jorge; Barkun, Jeffrey; Tamblyn, Robyn

2017-04-01

To describe the usage of a novel application (The FLOW) that allows mobile devices to be used for rounding and handoffs. The FLOW provides a view of patient data and the capacity to enter short notes via personal mobile devices. It was deployed using a "bring-your-own-device" model in 4 pilot units. Social network analysis (SNA) was applied to audit trails in order to visualize usage patterns. A questionnaire was used to describe user experience. Overall, 253 health professionals used The FLOW with their personal mobile devices from October 2013 to March 2015. In pediatric and neonatal intensive care units (ICUs), a median of 26-26.5 notes were entered per user per day. Visual network representation of app entries showed that usage patterns were different between the ICUs. In 127 questionnaires (50%), respondents reported using The FLOW most often to enter notes and for handoffs. The FLOW was perceived as having improved patient care by 57% of respondents, compared to usual care. Most respondents (86%) wished to continue using The FLOW. This study shows how a handoff and rounding tool was quickly adopted in pediatric and neonatal ICUs in a hospital setting where patient charts were still paper-based. Originally developed as a tool to support informal documentation using smartphones, it was adapted to local practices and expanded to print sign-out documents and import notes within the medicolegal record with desktop computers. Interestingly, even if not supported by the nursing administrative authorities, the level of use for data entry among nurses and doctors was similar in all units, indicating close collaboration in documentation practices in these ICUs. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Weaning from mechanical ventilation: factors that influence intensive care nurses' decision-making.

PubMed

Tingsvik, Catarina; Johansson, Karin; Mårtensson, Jan

2015-01-01

The aim of the study was to describe the factors that influence intensive care nurses' decision-making when weaning patients from mechanical ventilation. Patients with failing vital function may require respiratory support. Weaning from mechanical ventilation is a process in which the intensive care nurse participates in both planning and implementation. A qualitative approach was used. The data were collected by means of semi-structured interviews with 22 intensive care nurses. The interviews were transcribed and analysed using qualitative content analysis. One theme emerged: 'A complex nursing situation where the patient receives attention and which is influenced by the current care culture'. There was consensus that the overall assessment of the patient made by the intensive care nurse was the main factor that influenced the decision-making process. This assessment was a continuous process consisting of three factors: the patient's perspective as well as her/his physical and mental state. On the other hand, there was a lack of consensus about what other factors influenced the decision-making process. These factors included the care culture constituted by the characteristics of the team, the intensive care nurses' professional skills, personalities and ability to be present. The individual overall assessment of the patient enabled nursing care from a holistic perspective. Furthermore, the weaning process can be more effective and potential suffering reduced by creating awareness of the care culture's impact on the decision-making process. © 2014 British Association of Critical Care Nurses.

Understanding and safeguarding patient dignity in intensive care.

PubMed

Nyholm, Linda; Koskinen, Camilla A-L

2017-06-01

Dignity has been highlighted in previous research as one of the most important ethical concerns in nursing care. According to Eriksson, dignified caring is related to treating the patient as a unique human being and respecting human value. Intensive care unit patients are vulnerable to threatened dignity, and maintaining dignity may be challenging as a consequence of critical illness. The aim is to highlight how nurses in an intensive care setting understand patient dignity, what threatens patient dignity and how nurses can safeguard patient dignity. Research design and participants: Data materials were collected through a survey questionnaire which contained open questions about patient dignity, and the text was analysed using hermeneutic reading and text interpretation. Totally, 25 nurses employed in an intensive care unit in Finland participated in the study. Ethical considerations: The study follows the guidelines for good scientific practice by the Finnish Advisory Board on Research Integrity and the ethical principles according to the Declaration of Helsinki. Findings revealed that nurses recognize the patients' absolute dignity by regarding them as unique human beings. The nurses also recognize the importance of shared humanity in preserving patient dignity. Intensive care patients' dignity is threatened by negative attitudes and when their integrity is not being protected. Dignity is also threatened when patients and nurses are not part of the patients' care and patient care decisions, when patients receive care against their will and because of the acute nature of intensive care.

E-nursing documentation as a tool for quality assurance.

PubMed

Rajkovic, Vladislav; Sustersic, Olga; Rajkovic, Uros

2006-01-01

The article presents the results of a project with which we describe the reengineering of nursing documentation. Documentation in nursing is an efficient tool for ensuring quality health care and consequently quality patient treatment along the whole clinical path. We have taken into account the nursing process and patient treatment based on Henderson theoretical model of nursing that consists of 14 basic living activities. The model of new documentation enables tracing, transparency, selectivity, monitoring and analyses. All these factors lead to improvements of a health system as well as to improved safety of patients and members of nursing teams. Thus the documentation was developed for three health care segments: secondary and tertiary level, dispensaries and community health care. The new quality introduced to the documentation process by information and communication technology is presented by a database model and a software prototype for managing documentation.

The Intensive care unit specialist: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine.

PubMed

Amin, Pravin; Fox-Robichaud, Alison; Divatia, J V; Pelosi, Paolo; Altintas, Defne; Eryüksel, Emel; Mehta, Yatin; Suh, Gee Young; Blanch, Lluís; Weiler, Norbert; Zimmerman, Janice; Vincent, Jean-Louis

2016-10-01

The role of the critical care specialist has been unequivocally established in the management of severely ill patients throughout the world. Data show that the presence of a critical care specialist in the intensive care unit (ICU) environment has reduced morbidity and mortality, improved patient safety, and reduced length of stay and costs. However, many ICUs across the world function as "open ICUs," in which patients may be admitted under a primary physician who has not been trained in critical care medicine. Although the concept of the ICU has gained widespread acceptance amongst medical professionals, hospital administrators and the general public; recognition and the need for doctors specializing in intensive care medicine has lagged behind. The curriculum to ensure appropriate training around the world is diverse but should ideally meet some minimum standards. The World Federation of Societies of Intensive and Critical Care Medicine has set up a task force to address issues concerning the training, functions, roles, and responsibilities of an ICU specialist. Copyright © 2016 Elsevier Inc. All rights reserved.

Is more neonatal intensive care always better? Insights from a cross-national comparison of reproductive care.

PubMed

Thompson, Lindsay A; Goodman, David C; Little, George A

2002-06-01

Despite high per capita health care expenditure, the United States has crude infant survival rates that are lower than similarly developed nations. Although differences in vital recording and socioeconomic risk have been studied, a systematic, cross-national comparison of perinatal health care systems is lacking. To characterize systems of reproductive care for the United States, Australia, Canada, and the United Kingdom, including a detailed analysis of neonatal intensive care and mortality. Comparison of selected indicators of reproductive care and mortality from 1993-2000 through a systematic review of journal and government publications and structured interviews of leaders in perinatal and neonatal care. Compared with the other 3 countries, the United States has more neonatal intensive care resources yet provides proportionately less support for preconception and prenatal care. Unlike the United States, the other countries provided free family planning services and prenatal and perinatal physician care, and the United Kingdom and Australia paid for all contraception. The United States has high neonatal intensive care capacity, with 6.1 neonatologists per 10 000 live births; Australia, 3.7; Canada, 3.3; and the United Kingdom, 2.7. For intensive care beds, the United States has 3.3 per 10 000 live births; Australia and Canada, 2.6; and the United Kingdom, 0.67. Greater neonatal intensive care resources were not consistently associated with lower birth weight-specific mortality. The relative risk (United States as reference) of neonatal mortality for infants <1000 g was 0.84 for Australia, 1.12 for Canada, and 0.99 for the United Kingdom; for 1000 to 2499 g infants, the relative risk was 0.97 for Australia, 1.26 for Canada, and 0.95 for the United Kingdom. As reported elsewhere, low birth weight rates were notably higher in the United States, partially explaining the high crude mortality rates. The United States has significantly greater neonatal intensive care resources per capita, compared with 3 other developed countries, without having consistently better birth weight-specific mortality. Despite low birth weight rates that exceed other countries, the United States has proportionately more providers per low birth weight infant, but offers less extensive preconception and prenatal services. This study questions the effectiveness of the current distribution of US reproductive care resources and its emphasis on neonatal intensive care.

The effect of intensive care unit environments on nurse perceptions of family presence during resuscitation and invasive procedures.

PubMed

Carroll, Diane L

2014-01-01

In a growing number of requests, family members are asking for proximity to their family member during resuscitation and invasive procedures. The objective of this study was to measure the impact of intensive care unit environments on nurse perception of family presence during resuscitation and invasive procedures. The study used a descriptive survey design with nurses from 9 intensive care units using the Family Presence Self-confidence Scale for resuscitation/invasive procedures that measures nurses' perception of self-confidence and Family Presence Risk-Benefit Scale for resuscitation and invasive procedures that measures nurses' perception of risks/benefits related to managing resuscitation and invasive procedures with family present. There were 207 nurses who responded: 14 male and 184 female nurses (9 missing data), with mean age of 41 ± 11 years, with a mean of 15 years in critical care practice. The environments were defined as surgical (n = 68), medical (n = 43), pediatric/neonatal (n = 34), and mixed adult medical/surgical (n = 36) intensive care units. There were significant differences in self-confidence, with medical and pediatric intensive care unit nurses rating more self-confidence for family presence during resuscitation (F = 7.73, P < .000) and invasive procedures (F = 6.41, P < .000). There were significant differences in risks/benefits with medical and pediatric intensive care unit nurses rating lower risk and higher benefit for resuscitation (F = 7.73, P < .000). Perceptions of family presence were significantly higher for pediatric and medical intensive care unit nurses. Further education and support may be needed in the surgical and mixed intensive care units. Evidence-based practice guidelines that are family centered can define the procedures and resources for family presence, to ultimately promote professional practice.

Clinical Benefits, Costs, and Cost-Effectiveness of Neonatal Intensive Care in Mexico

PubMed Central

Profit, Jochen; Lee, Diana; Zupancic, John A.; Papile, LuAnn; Gutierrez, Cristina; Goldie, Sue J.; Gonzalez-Pier, Eduardo; Salomon, Joshua A.

2010-01-01

Background Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico. Methods and Findings A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24–26, 27–29, and 30–33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24–26, 27–29, and 30–33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses. Conclusions Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis. Please see later in the article for the Editors' Summary PMID:21179496

Morphine Glucuronidation and Elimination in Intensive Care Patients: A Comparison with Healthy Volunteers.

PubMed

Ahlers, Sabine J G M; Välitalo, Pyry A J; Peeters, Mariska Y M; Gulik, Laura van; van Dongen, Eric P A; Dahan, Albert; Tibboel, Dick; Knibbe, Catherijne A J

2015-11-01

Although morphine is used frequently to treat pain in the intensive care unit, its pharmacokinetics has not been adequately quantified in critically ill patients. We evaluated the glucuronidation and elimination clearance of morphine in intensive care patients compared with healthy volunteers based on the morphine and morphine-3-glucuronide (M3G) concentrations. A population pharmacokinetic model with covariate analysis was developed with the nonlinear mixed-effects modeling software (NONMEM 7.3). The analysis included 3012 morphine and M3G concentrations from 135 intensive care patients (117 cardiothoracic surgery patients and 18 critically ill patients), who received continuous morphine infusions adapted to individual pain levels, and 622 morphine and M3G concentrations from a previously published study of 20 healthy volunteers, who received an IV bolus of morphine followed by a 1-hour infusion. For morphine, a 3-compartment model best described the data, whereas for M3G, a 1-compartment model fits best. In intensive care patients with a normal creatinine concentration, a decrease of 76% was estimated in M3G clearance compared with healthy subjects, conditional on the M3G volume of distribution being the same in intensive care patients and healthy volunteers. Furthermore, serum creatinine concentration was identified as a covariate for both elimination clearance of M3G in intensive care patients and unchanged morphine clearance in all patients and healthy volunteers. Under the assumptions in the model, M3G elimination was significantly decreased in intensive care patients when compared with healthy volunteers, which resulted in substantially increased M3G concentrations. Increased M3G levels were even more pronounced in patients with increased serum creatinine levels. Model-based simulations show that, because of the reduction in morphine clearance in intensive care patients with renal failure, a 33% reduction in the maintenance dose would result in morphine serum concentrations equal to those in healthy volunteers and intensive care patients with normal renal function, although M3G concentrations remain increased. Future pharmacodynamic investigations are needed to identify target concentrations in this population, after which final dosing recommendations can be made.

Clinical course of sepsis in children with acute leukemia admitted to the pediatric intensive care unit.

PubMed

Singer, Kanakadurga; Subbaiah, Perla; Hutchinson, Raymond; Odetola, Folafoluwa; Shanley, Thomas P

2011-11-01

To describe the clinical course, resource use, and mortality of patients with leukemia admitted to the pediatric intensive care unit with sepsis and nonsepsis diagnoses over a 10-yr period. Retrospective analysis. Tertiary medical-surgical pediatric intensive care unit at C.S. Mott Children's Hospital, University of Michigan. All patients with leukemia admitted to the pediatric intensive care unit from January 1, 1998, to December 31, 2008. None; chart review. Clinical course was characterized by demographics, leukemia diagnosis, phase of therapy, leukocyte count on admission, presence of sepsis, steroid administration, intensity of care, and Pediatric Risk of Mortality score on admission to the pediatric intensive care unit. The primary outcome was survival to pediatric intensive care unit discharge. Among 68 single admissions to the pediatric intensive care unit with leukemia during the study period, 33 (48.5%) were admitted with sepsis. Admission to the pediatric intensive care unit for sepsis was associated with greater compromise of hemodynamic and renal function and use of stress dose steroids (p = .016), inotropic and/or vasopressor drugs (p = .01), and renal replacement therapy (p = .028) than nonsepsis admission. There was higher mortality among children with sepsis than other diagnoses (52% vs. 17%, p = .004). Also, mortality among children with sepsis was higher among those with acute lymphoblastic leukemia (60% vs. 44%) compared with acute myelogenous leukemia. Administration of stress dose steroids was associated with higher mortality (50% vs. 17%, p = .005) and neutropenia. Patients with acute lymphoblastic leukemia and sepsis showed the greatest mortality and resource use. Patients with acute leukemia and sepsis had a much higher mortality rate compared with previously described sepsis mortality rates for the general pediatric intensive care unit patient populations. Patients who received steroids had an increased mortality rate, but given the retrospective nature of this study, we maintain a position of equipoise with regard to this association. Variation in mortality and resource use by leukemia type suggests further research is needed to develop targeted intervention strategies to enhance patient outcomes.

Assessing changes in a patient's condition - perspectives of intensive care nurses.

PubMed

Kvande, Monica; Delmar, Charlotte; Lykkeslet, Else; Storli, Sissel Lisa

2017-03-01

To explore the phenomenon of assessing changes in patients' conditions in intensive care units from the perspectives of experienced intensive care nurses. Providing safe care for patients in intensive care units requires an awareness and perception of the signs that indicate changes in a patient's condition. Nurses in intensive care units play an essential role in preventing the deterioration of a patient's condition and in improving patient outcomes. This hermeneutic phenomenological study conducted close observations and in-depth interviews with 11 intensive care nurses. The nurses' experience ranged from 7 to 28 years in the intensive care unit. Data were collected at two intensive care units in two Norwegian university hospitals. The analysis was performed using the reflective methods of van Manen. An overarching theme of 'sensitive situational attention' was identified, in which the nurses were sensitive in relation to a patient and understood the significance of a given situation. This theme was further unfolded in four subthemes: (1) being sensitive and emotionally present, (2) being systematic and concentrating, (3) being physically close to the bedside and (4) being trained and familiar with the routines. Nurses understand each patient's situation and foresee clinical eventualities through a sensitive and attentive way of thinking and working. This requires nurses to be present at the bedside with both their senses (sight, hearing, smell and touch) and emotions and to work in a concentrated and systematic manner. Knowledge about the unique patient exists in interplay with past experiences and medical knowledge, which are essential for nurses to understand the situation. Clinical practice should develop routines that enable nurses to be present at the bedside and to work in a concentrated and systematic manner. Furthermore, providing safe care requires nurses to be sensitive and attentive to each patient's unique situation. © 2016 British Association of Critical Care Nurses.

Family members' lived experiences of everyday life after intensive care treatment of a loved one: a phenomenological hermeneutical study.

PubMed

Frivold, Gro; Slettebø, Åshild; Dale, Bjørg

2016-02-01

To illuminate relatives' experiences of everyday life after a loved one's stay in an intensive care unit. Relatives of intensive care patients experience considerable stress that can have a long-lasting effect on their everyday lives. Relatives frequently report anxiety, depression and complicated grief as a result of their experiences in the intensive care unit. A qualitative design was chosen. Thirteen relatives were interviewed 3 months to 1 year after the discharge or death of an intensive care unit patient. A phenomenological hermeneutical method was used to explore family members' lived experiences upon returning home after their loved ones' stay in the intensive care unit. Two themes emerged from the analysis of the data: (1) changes in everyday life and emotional reactions, and (2) managing changes and need of support and follow-up from the ICU. Family members experience changes in emotions, roles and responsibilities after returning home. They must maintain control of themselves and adapt to the changes to face the future. They cope by using their personal resources and support from others. Some are in further need of follow-up from the intensive care unit staff. Nursing education could focus increasingly more on the significance of communication and personal support, which helps family members cope during patients' stay and experience a sense of personal strength when returning home. Further research should address how to identify and support those with special needs after the intensive care unit stay. © 2016 John Wiley & Sons Ltd.

Stressors in the relatives of patients admitted to an intensive care unit.

PubMed

Barth, Angélica Adam; Weigel, Bruna Dorfey; Dummer, Claus Dieter; Machado, Kelly Campara; Tisott, Taís Montagner

2016-09-01

To identify and stratify the main stressors for the relatives of patients admitted to the adult intensive care unit of a teaching hospital. Cross-sectional descriptive study conducted with relatives of patients admitted to an intensive care unit from April to October 2014. The following materials were used: a questionnaire containing identification information and demographic data of the relatives, clinical data of the patients, and 25 stressors adapted from the Intensive Care Unit Environmental Stressor Scale. The degree of stress caused by each factor was determined on a scale of values from 1 to 4. The stressors were ranked based on the average score obtained. The main cause of admission to the intensive care unit was clinical in 36 (52.2%) cases. The main stressors were the patient being in a state of coma (3.15 ± 1.23), the patient being unable to speak (3.15 ± 1.20), and the reason for admission (3.00 ± 1.27). After removing the 27 (39.1%) coma patients from the analysis, the main stressors for the relatives were the reason for admission (2.75 ± 1.354), seeing the patient in the intensive care unit (2.51 ± 1.227), and the patient being unable to speak (2.50 ± 1.269). Difficulties in communication and in the relationship with the patient admitted to the intensive care unit were identified as the main stressors by their relatives, with the state of coma being predominant. By contrast, the environment, work routines, and relationship between the relatives and intensive care unit team had the least impact as stressors.

Documentation for Students in Residential Care: Network of Relations of Human and Non-Human Actants

ERIC Educational Resources Information Center

Severinsson, Susanne

2016-01-01

Swedish and international research points to serious problems for the education of students with social, emotional and behavioural difficulties (SEBD) in the care of social welfare, for example, in residential care. The aim of this article is to elucidate how documentation, care plans (CPs) and individual educational plans (IEPs) outline the…

Variability in the clinical distributions of Candida species and the emergence of azole-resistant non-Candida albicans species in public hospitals in the Midwest region of Brazil.

PubMed

Mattos, Karine; Rodrigues, Luana Carbonera; Oliveira, Kelly Mari Pires de; Diniz, Pedro Fernando; Marques, Luiza Inahê; Araujo, Adriana Almeida; Chang, Marilene Rodrigues

2017-01-01

Incidence and antifungal susceptibility of Candida spp. from two teaching public hospitals are described. The minimum inhibitory concentrations of fluconazole, voriconazole, itraconazole, and amphotericin B were determined using Clinical Laboratory Standard Institute broth microdilution and genomic differentiation using PCR. Of 221 Candida isolates, 50.2% were obtained from intensive care unit patients; 71.5% were recovered from urine and 9.1% from bloodstream samples. Candida parapsilosis sensu stricto was the most common candidemia agent. We observed variations in Candida species distribution in hospitals in the same geographic region and documented the emergence of non-C. albicans species resistant to azoles.

In their own words: Life at adulthood after very premature birth.

PubMed

Saigal, Saroj

2016-12-01

Very premature infants born in the last century following the early days of post-neonatal intensive care have demonstrated an array of physical, emotional, and mental health problems as they approach their third and fourth decades. These outcomes have been well documented by several international investigators. However, there is a paucity of information on the personal perspectives of these individuals with regard to their own quality of life, their hopes and their fears. This article will focus on the objective information from the published literature and how it differs from the personal perspectives of former very premature infants. Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.

Knowledge enabled plan of care and documentation prototype.

PubMed

DaDamio, Rebecca; Gugerty, Brian; Kennedy, Rosemary

2006-01-01

There exist significant challenges in integrating the plan of care into documentation and point of care operational processes. A plan of care is often a static artifact that meets regulatory standards with limited influence on supporting goal-directed care delivery processes. Although this prototype is applicable to many clinical disciplines, we will highlight nursing processes in demonstrating a knowledge-driven computerized solution that fully integrates the plan of care within documentation. The knowledge-driven solution reflects evidenced-based practice; is an effective tool for managing problems, orders/interventions, and the patient's progress towards expected outcomes; meets regulatory standards; and drives quality and process improvement. The knowledge infrastructure consists of fully represented terminology, structured clinical expressions utilizing the controlled terminology and clinical knowledge representing evidence-based practice.

A framework for conducting follow-up meetings with parents after a child's death in the pediatric intensive care unit.

PubMed

Eggly, Susan; Meert, Kathleen L; Berger, John; Zimmerman, Jerry; Anand, Kanwaljeet J S; Newth, Christopher J L; Harrison, Rick; Carcillo, Joseph; Dean, J Michael; Willson, Douglas F; Nicholson, Carol

2011-03-01

To describe a framework to assist pediatric intensive care unit physicians in conducting follow-up meetings with parents after their child's death. Many childhood deaths occur in pediatric intensive care units. Parents of children who die in pediatric intensive care units often desire a follow-up meeting with the physician(s) who cared for their child. Prior research conducted by the Collaborative Pediatric Critical Care Research Network on the experiences and perspectives of bereaved parents and pediatric intensive care unit physicians regarding the desirability, content, and conditions of follow-up meetings. The framework includes suggestions for inviting families to follow-up meetings (i.e., developing an institutional system, invitation timing, and format); preparing for the meeting (i.e., assessing family preferences; determining location, attendees, and discussion topics; reviewing medical and psychosocial history); structure of the meeting (i.e., opening, closing, and developing a meeting agenda); communicating effectively during the meeting; and follow-up for both parents and physicians. This framework is based on the experience and perspectives of bereaved parents and pediatric intensive care unit physicians. Future research should be conducted to determine the extent to which physician-parent follow-up meetings provide a benefit to parents, families, physicians, and other healthcare providers participating in these encounters.

Development and initial validation of the Swedish Family Satisfaction Intensive Care Questionnaire (SFS-ICQ).

PubMed

Thermaenius, Johan; Schandl, Anna; Sluys, Kerstin Prignitz

2018-06-20

Measuring patients satisfaction is an important part of continuous quality improvement in health care. In intensive care, family satisfaction is often used as a proxy for patient experience. At present, no suitable instrument to measure this has been fully validated in Sweden. The purpose of this study was to develop and validate a questionnaire intended to evaluate families' satisfaction of quality of care in Swedish intensive care units. Based on literature and the modification of pertinent items in two existing North American questionnaires, a Swedish questionnaire was developed. Content validity was assessed by experts, and the cognitive method Think Aloud was used with twelve family members of intensive care patients in two different intensive care units. Data was analysed using qualitative content analysis. Seven items in the questionnaire were identified as problematic, causing eight problems concerning questioning of content and 23 concerning misunderstanding. Six of these items were changed in order to be understood the way they were intended, and one item was removed. A family satisfaction questionnaire applicable in Swedish intensive care units has been developed and validated for respondents' understanding of the questions being asked. However, further psychometric testing should be performed when more data are available. Copyright © 2018 Elsevier Ltd. All rights reserved.

Concordance Between Veterans' Self-Report and Documentation of Surrogate Decision Makers: Implications for Quality Measurement.

PubMed

Garner, Kimberly K; Dubbert, Patricia; Lensing, Shelly; Sullivan, Dennis H

2017-01-01

The Measuring What Matters initiative of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association identified documentation of a surrogate decision maker as one of the top 10 quality indicators in the acute hospital and hospice settings. To better understand the potential implementation of this Measuring What Matters quality measure #8, Documentation of Surrogate in outpatient primary care settings by describing primary care patients' self-reported identification and documentation of a surrogate decision maker. Examination of patient responses to self-assessment questions from advance health care planning educational groups conducted in one medical center primary care clinic and seven community-based outpatient primary care clinics. We assessed the concordance between patient reports of identifying and naming a surrogate decision maker and having completed an advance directive (AD) with presence of an AD in the electronic medical record. Of veterans without a documented AD on file, more than half (66%) reported that they had talked with someone they trusted and nearly half (52%) reported that they had named someone to communicate their preferences. Our clinical project data suggest that many more veterans may have initiated communications with surrogate decision makers than is evident in the electronic medical record. System changes are needed to close the gap between veterans' plans for a surrogate decision maker and the documentation available to acute care health care providers. Published by Elsevier Inc.

[Clinical pattern of patients cared for at pain clinic by first time].

PubMed

Covarrubias-Gómez, Alfredo; Guevara-López, Uriah; Lara-Solares, Argelia; Tamayo-Valenzuela, Antonio C; Salinas-Cruz, Jorge; Torres-González, Rubén

2008-01-01

Epidemiological studies about frequency and prevalence of chronic pain in Mexico are scarce. However, it has been documented that chronic pain is a frequent complain in general population and mainly in older adults. It influences physical patient capacity and it impacts social health services with its expensive cost. Our objective was to identify the clinical pattern of patients attending at a Pain Clinic by first time. We conducted a descriptive-retrospective study, in a five years period, with patients attending a Pain Clinic by first time. We collected demographic data and information about the cause of pain (malignant vs. non-malignant etiology), its intensity by visual analogue scale (VAS), and type (somatic, visceral, neuropathic and mixed). 1453 clinical records were analyzed. Women were more affected; the average age was 59 +/- 16 years; non-malignant pain and neuropathic pain were more frequent; the intensity average was 6 +/- 2, and it increases with age. It is necessary to generate epidemiological studies to fundament health policies regarding the management of these patients.

Recent International Documents and Journal Articles from the ERIC Database.

ERIC Educational Resources Information Center

International Journal of Early Years Education, 1998

1998-01-01

Annotates recent international documents and journal articles from the ERIC database. Document topics include racial equality, and balancing early childhood education and work. Journal article topics include foster care in Iraqi Kurdistan; child care in Sweden; teacher-child interaction in Australian centers; teacher education in Brazil, Iceland,…

Fatigue in Intensive Care Nurses and Related Factors.

PubMed

Çelik, Sevim; Taşdemir, Nurten; Kurt, Aylin; İlgezdi, Ebru; Kubalas, Özge

2017-10-01

Fatigue negatively affects the performance of intensive care nurses. Factors contributing to the fatigue experienced by nurses include lifestyle, psychological status, work organization and sleep problems. To determine the level of fatigue among nurses working in intensive care units and the related factors. This descriptive study was conducted with 102 nurses working in intensive care units in the West Black Sea Region of Turkey. Data were collected between February and May 2014 using a personal information form, the Visual Analogue Scale for Fatigue (VAS-F), the Hospital Anxiety and Depression Scale and the Pittsburg Sleep Quality Index. The intensive care nurses in the study were found to be experiencing fatigue. Significant correlations were observed between scores on the VAS-F Fatigue and anxiety (p=0.01), depression (p=0.002), and sleep quality (p<0.001). Anxiety, depression and quality of sleep were significantly affected by the intensive care nurses' levels of fatigue. These results can be of benefit in taking measures which may be used to reduce fatigue in nurses, especially the fatigue related to work organization and social life.

[Indication for antimycotic therapy for tracheobronchial candidosis under artificial ventilation].

PubMed

Grossherr, M; Sedemund-Adib, Beate; Klotz, K-F

2005-01-01

Tracheobronchial candidosis is an impetuous complication in intensive care medicine. This article presents a concept to compare diagnostic procedure, Candida species and resistant species of different intensive care units with each other. This concept should encourage bench marking between similar intensive care units. The report and retrospective analysis of the intensive care course offer the opportunity to reflect own decisions and to adjust them to the current therapy strategies. Both procedures should improve the antimycotic therapy for intensive care units and should avoid the occurrence of resistant species. Candida species are often detected in the respiratory system of ventilated patients in intensive care, but this alone is no indication for antimycotic therapy. A strict retention is recommended, but this retention is diminished by an unclear infection, critical situation of the patient in the case of multiple organ failure, additional infection and long term ventilation. A therapy strategy for individual situations should be established and a close diagnostic procedure should be performed. A positive blood culture or detection of Candida species in two or more diagnostic materials indicate an early antimycotic therapy.

Urinary tract infections due to Trichosporon spp. in severely ill patients in an intensive care unit

PubMed Central

Mattede, Maria das Graças Silva; Piras, Cláudio; Mattede, Kelly Dematte Silva; Ferrari, Aline Trugilho; Baldotto, Lorena Simões; Assbu, Michel Silvestre Zouain

2015-01-01

Objective To evaluate the incidence of urinary tract infections due to Trichosporon spp. in an intensive care unit. Methods This descriptive observational study was conducted in an intensive care unit between 2007 and 2009. All consecutive patients admitted to the intensive care unit with a confirmed diagnosis were evaluated. Results Twenty patients presented with urinary tract infections due to Trichosporon spp. The prevalence was higher among men (65%) and among individuals > 70 years of age (55%). The mortality rate was 20%. The average intensive care unit stay was 19.8 days. The onset of infection was associated with prior use of antibiotics and was more frequent in the fall and winter. Conclusion Infection due to Trichosporon spp. was more common in men and among those > 70 years of age and was associated with the use of an indwelling urinary catheter for more than 20 days and with the use of broadspectrum antibiotics for more than 14 days. In addition, patients with urinary infection due to Trichosporon spp. were most often hospitalized in intensive care units in the fall and winter periods. PMID:26465246

Brain Damage Treated with Non Proven Intensive Training 2003-2011: A Norwegian Cost Analysis

PubMed Central

Norum, Jan; Ramsvik, Arnborg; Tjeldnes, Knut

2012-01-01

Objectives: There has been an increased request for intensive training and rehabilitation of patients with brain damage in Norway. These programs are demanding with regard to personnel, travelling, time and economic resources. We aimed to indicate cost and gain to make these programs cost-effective. Methods: A retrospective study included all patients referred to the Northern Norway Regional Health Authority (NNRHA) trust during the nine years period 2003-2011. All referrals to the NNRHA trust for the economic coverage of foreign based rehabilitation or habilitation programs (The Advanced Bio-Mechanical Rehabilitation (ABR), Institutes of Achievement of Human Potential program (IAHP) (Doman method), Family Hope Center (FHC) program and the Kozijavkin method) were included. 17 patients were detected and 15 fulfilled the inclusion criteria for funding. Median age was 8 years (1-31 years). Cost from the specialist health care point of view was calculated. A cut-off limit of €57,000/quality adjusted life year (QALY) and a 4% discount rate was employed. Results: The undiscounted cost per patient enrolled was calculated €133,210 (discounted €121,348). To make these therapies cost effective, a total of at least 2.13 QALYs (2.34 undiscounted QALYs) must be gained per patient enrolled. Such a gain could not be indicated and we doubt it is achievable. Conclusion: Non-proven intensive training programs for patients with brain damage are costly. As long as their effect has not been documented, health care services should not spend resources on these programs outside clinical trials. PMID:23121754

Modernization is Associated with Intensive Breastfeeding Patterns in the Bolivian Amazon

PubMed Central

Veile, Amanda; Martin, Melanie; McAllister, Lisa

2014-01-01

For many traditional, non-industrialized populations, intensive and prolonged breastfeeding buffers infant health against poverty, poor sanitation, and limited health care. Due to novel influences on local economies, values, and beliefs, the traditional and largely beneficial breastfeeding patterns of such populations may be changing to the detriment of infant health. To assess if and why such changes are occurring in a traditional breastfeeding population, we document breastfeeding patterns in the Bolivian Tsimane, a forager-horticulturalist population in the early stages of modernization. Three predictions are developed and tested to evaluate the general hypothesis that modernizing influences encourage less intensive breastfeeding in the Tsimane: 1) Tsimane mothers in regions of higher infant mortality will practice more intensive BF; 2) Tsimane mothers who are located closer to a local market town will practice more intensive BF; and 3) Older Tsimane mothers will practice more intensive BF. Predictions were tested using a series of maternal interviews (from 2003-2011, n=215) and observations of mother-infant dyads (from 2002-2007, n=133). Tsimane breastfeeding patterns were generally intensive: 72% of mothers reported initiating BF within a few hours of birth, mean (± SD) age of CF introduction was 4.1±2.0 months, and mean (± SD) weaning age was 19.2±7.3 months. There was, however, intra-population variation in several dimensions of breastfeeding (initiation, frequency, duration, and complementary feeding). Contrary to our predictions, breastfeeding was most intensive in the most modernized Tsimane villages, and maternal age was not a significant predictor of breastfeeding patterns. Regional differences accounted for variation in most dimensions of breastfeeding (initiation, frequency, and complementary feeding). Future research should therefore identify constraints on breastfeeding in the less modernized Tsimane regions, and examine the formation of maternal beliefs regarding infant feeding. PMID:24444850

The health care system is making 'too much noise' to provide family-centred care in neonatal intensive care units: Perspectives of health care providers and hospital administrators.

PubMed

Benzies, Karen M; Shah, Vibhuti; Aziz, Khalid; Lodha, Abhay; Misfeldt, Renée

2018-05-11

To describe the perspectives of health care providers and hospital administrators on their experiences of providing care for infants in Level II neonatal intensive care units and their families. We conducted 36 qualitative interviews with neonatal health care providers and hospital administrators and analysed data using a descriptive interpretive approach. 10 Level II Neonatal Intensive Care Units in a single, integrated health care system in one Canadian province. Three major themes emerged: (1) providing family-centred care, (2) working amidst health care system challenges, and (3) recommending improvements to the health care system. The overarching theme was that the health care system was making 'too much noise' for health care providers and hospital administrators to provide family-centred care in ways that would benefit infants and their families. Recommended improvements included: refining staffing models, enhancing professional development, providing tools to deliver consistent care, recognising parental capacity to be involved in care, strengthening continuity of care, supporting families to be with their infant, and designing family-friendly environments. When implementing family-centred care initiatives, health care providers and hospital administrators need to consider the complexity of providing care in Level II Neonatal Intensive Care Units, and recognise that health care system changes may be necessary to optimise implementation. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.

Utilisation of home-based physician, nurse and personal support worker services within a palliative care programme in Ontario, Canada: trends over 2005-2015.

PubMed

Sun, Zhuolu; Laporte, Audrey; Guerriere, Denise N; Coyte, Peter C

2017-05-01

With health system restructuring in Canada and a general preference by care recipients and their families to receive palliative care at home, attention to home-based palliative care continues to increase. A multidisciplinary team of health professionals is the most common delivery model for home-based palliative care in Canada. However, little is known about the changing temporal trends in the propensity and intensity of home-based palliative care. The purpose of this study was to assess the propensity to use home-based palliative care services, and once used, the intensity of that use for three main service categories: physician visits, nurse visits and care by personal support workers (PSWs) over the last decade. Three prospective cohort data sets were used to track changes in service use over the period 2005 to 2015. Service use for each category was assessed using a two-part model, and a Heckit regression was performed to assess the presence of selectivity bias. Service propensity was modelled using multivariate logistic regression analysis and service intensity was modelled using log-transformed ordinary least squares regression analysis. Both the propensity and intensity to use home-based physician visits and PSWs increased over the last decade, while service propensity and the intensity of nurse visits decreased. Meanwhile, there was a general tendency for service propensity and intensity to increase as the end of life approached. These findings demonstrate temporal changes towards increased use of home-based palliative care, and a shift to substitute care away from nursing to less expensive forms of care, specifically PSWs. These findings may provide a general idea of the types of services that are used more intensely and require more resources from multidisciplinary teams, as increased use of home-based palliative care has placed dramatic pressures on the budgets of local home and community care organisations. © 2016 John Wiley & Sons Ltd.

Physical and rehabilitation medicine (PRM) care pathways: "patients after rotator cuff tear surgery".

PubMed

Ribinik, P; Calmels, P; Barrois, B; Le Moine, F; Yelnik, A P

2011-11-01

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Federation of PRM (Fedmer). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after rotator cuff tear surgery are classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients' needs, in accordance with the International Classification of Functioning (ICF) (WHO). 2011 Elsevier Masson SAS. All rights reserved.

Physical and rehabilitation medicine (PRM) care pathways: "patients after knee ligament surgery".

PubMed

Calmels, P; Ribinik, P; Barrois, B; Le Moine, F; Yelnik, A-P

2011-11-01

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Federation of PRM (Fedmer). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after knee ligament surgery are classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients' needs, in accordance with the International Classification of Functioning (WHO). 2011 Elsevier Masson SAS. All rights reserved.

Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review.

PubMed

Lewis, Ebony; Cardona-Morrell, Magnolia; Ong, Kok Y; Trankle, Steven A; Hillman, Ken

2016-10-01

Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient's wishes or delayed physician-family communications on preference. To determine whether advance care documentation encourages healthcare professional's timely engagement in end-of-life discussions. Systematic review of the English language articles published from January 2000 to April 2015. EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists. A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available. Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians' confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review. © The Author(s) 2016.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life: An Analysis of Data from the BEACON Trial.

PubMed

Kvale, Elizabeth; Dionne-Odom, J Nicholas; Redden, David T; Bailey, F Amos; Bakitas, Marie; Goode, Patricia S; Williams, Beverly R; Haddock, Kathlyn Sue; Burgio, Kathryn L

2015-06-01

The use of physical restraints in dying patients may be a source of suffering and loss of dignity. Little is known about the prevalence or predictors for restraint use at end of life in the hospital setting. The objective was to determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults. Secondary analysis was performed on data from the "Best Practices for End-of-Life Care for Our Nation's Veterans" (BEACON) trial conducted between 2005 and 2011. Medical record data were abstracted from six Veterans Administration Medical Centers (VAMCs). Data on processes of care in the last seven days of life were abstracted from the medical records of 5476 who died in the six VAMCs. We prospectively identified potential risk factors for restraint use at the time of death from among the variables measured in the parent trial, including location of death, medications administered, nasogastric tube, intravenous (IV) fluids, family presence, and receipt of a palliative care consultation. Physical restraint use at time of death was documented in 890 decedents (16.3%). Restraint use varied by location of death, with patients in intensive settings being at higher risk. Restraint use was significantly more likely in patients with a nasogastric tube and those receiving IV fluids, benzodiazepines, or antipsychotics. This is the first study to document that one in six hospitalized veterans were restrained at the time of death and to identify predictors of restraint use. Further research is needed to identify intervention opportunities.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life: An Analysis of Data from the BEACON Trial

PubMed Central

Dionne-Odom, J. Nicholas; Redden, David T.; Bailey, F. Amos; Bakitas, Marie; Goode, Patricia S.; Williams, Beverly R.; Haddock, Kathlyn Sue; Burgio, Kathryn L.

2015-01-01

Abstract Background: The use of physical restraints in dying patients may be a source of suffering and loss of dignity. Little is known about the prevalence or predictors for restraint use at end of life in the hospital setting. Objective: The objective was to determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults. Methods: Secondary analysis was performed on data from the “Best Practices for End-of-Life Care for Our Nation's Veterans” (BEACON) trial conducted between 2005 and 2011. Medical record data were abstracted from six Veterans Administration Medical Centers (VAMCs). Data on processes of care in the last seven days of life were abstracted from the medical records of 5476 who died in the six VAMCs. We prospectively identified potential risk factors for restraint use at the time of death from among the variables measured in the parent trial, including location of death, medications administered, nasogastric tube, intravenous (IV) fluids, family presence, and receipt of a palliative care consultation. Results: Physical restraint use at time of death was documented in 890 decedents (16.3%). Restraint use varied by location of death, with patients in intensive settings being at higher risk. Restraint use was significantly more likely in patients with a nasogastric tube and those receiving IV fluids, benzodiazepines, or antipsychotics. Conclusions: This is the first study to document that one in six hospitalized veterans were restrained at the time of death and to identify predictors of restraint use. Further research is needed to identify intervention opportunities. PMID:25927909

A quantitative analysis of surgical capacity in Santa Cruz, Bolivia.

PubMed

Markin, Abraham; Barbero, Roxana; Leow, Jeffrey J; Groen, Reinou S; Skow, Evan J; Apelgren, Keith N; Kushner, Adam L; Nwomeh, Benedict C

2013-11-01

This investigation aimed to document surgical capacity at public medical centers in a middle-income Latin American country using the Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) survey tool. We applied the PIPES tool at six urban and 25 rural facilities in Santa Cruz, Bolivia. Outcome measures included the availability of items in five domains (Personnel, Infrastructure, Procedures, Equipment, and Supplies) and the PIPES index. PIPES indices were calculated by summing scores from each domain, dividing by the total number of survey items, and multiplying by 10. Thirty-one of the 32 public facilities that provide surgical care in Santa Cruz were assessed. Santa Cruz had at least 7.8 surgeons and 2.8 anesthesiologists per 100,000 population. However, these providers were unequally distributed, such that nine rural sites had no anesthesiologist. Few rural facilities had blood banking (4/25), anesthesia machines (11/25), postoperative care (11/25), or intensive care units (1/25). PIPES indices ranged from 5.7-13.2, and were significantly higher in urban (median 12.6) than rural (median 7.8) areas (P < 0.01). This investigation is novel in its application of a Spanish-language version of the PIPES tool in a middle-income Latin American country. These data document substantially greater surgical capacity in Santa Cruz than has been reported for Sierra Leone or Rwanda, consistent with Bolivia's development status. Unfortunately, surgeons are limited in rural areas by deficits in anesthesia and perioperative services. These results are currently being used to target local quality improvement initiatives. Copyright © 2013 Elsevier Inc. All rights reserved.

Use of Headings and Classifications by Physicians in Medical Narratives of EHRs

PubMed Central

Häyrinen, K.; Harno, K.; Nykänen, P.

2011-01-01

Objective The purpose of this study was to describe and evaluate patient care documentation by hospital physicians in EHRs and especially the use of national headings and classifications in these documentations Material and Methods The initial material consisted of a random sample of 3,481 medical narratives documented in EHRs during the period 2004-2005 in one department of a Finnish central hospital. The final material comprised a subset of 1,974 medical records with a focus on consultation requests and consultation responses by two specialist groups from 871 patients. This electronic documentation was analyzed using deductive content analyses and descriptive statistics. Results The physicians documented patient care in EHRs principally as narrative text. The medical narratives recorded by specialists were structured with headings in less than half of the patient cases. Consultation responses in general were more often structured with headings than consultation requests. The use of classifications was otherwise insignificant, but diagnoses were documented as ICD 10 codes in over 50% of consultation responses by both medical specialties. Conclusion There is an obvious need to improve the structuring of narrative text with national headings and classifications. According to the findings of this study, reason for care, patient history, health status, follow-up care plan and diagnosis are meaningful headings in physicians’ documentation. The existing list of headings needs to be analyzed within a consistent unified terminology system as a basis for further development. Adhering to headings and classifications in EHR documentation enables patient data to be shared and aggregated. The secondary use of data is expected to improve care management and quality of care. PMID:23616866

Obesity perceptions and documentation among primary care clinicians at a rural academic health center.

PubMed

Aleem, Sohaib; Lasky, Rosalind; Brooks, W Blair; Batsis, John A

2015-01-01

Obesity recognition in primary care is important to address the epidemic. We aimed to evaluate primary care clinician-reported documentation, management practices, beliefs and attitudes toward obesity compared to body mass index (BMI) calculation, obesity prevalence and actual documentation of obesity as an active problem in electronic health record in a rural academic center. Our target population for previously validated clinician survey was 56 primary care providers working at 3 sites. We used calendar year 2012 data for assessment of baseline system performance for metrics of documentation of BMI in primary care visits, and proportion of visits in patients with obesity with obesity as a problem. Standard statistical methods assessed the data. Survey response rate was 91%. Average age of respondents was 48.9 years and 62.7% were females. 72.5% clinicians reported having normal BMI. The majority of clinicians reported regularly documenting obesity as an active problem, and utilized motivational interviewing and basic good nutrition and healthy exercise. Clinicians identified lack of discipline and exercise time, access to unhealthy food and psychosocial issues as major barriers. Most denied disliking weight loss discussion or patients taking up too much time. In 21,945 clinic visits and 11,208 annual preventive care visits in calendar year 2012, BMI was calculated in 93% visits but obesity documentation as an active problem only 27% of patients meeting BMI criteria for obesity. Despite high clinician-reported documentation of obesity as an active problem, actual obesity documentation rates remained low in a rural academic medical center. Copyright © 2015 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

[Hospital management of acute respiratory failure: the role of the pulmonologist and of the respiratory intensive care unit].

PubMed

Scala, Raffaele

2009-04-01

Acute respiratory failure (ARF) is one of the most common and severe urgencies of the modern medicine which may require the application of mechanical ventilation and a careful monitoring of the patient's conditions. With the popularity of non-invasive ventilation and the interest of the pulmonologist for the care of the respiratory critical patient, in Italy there has been the spreading of Respiratory Intensive Care Units (RICU), which are as intermediate specialist structures in terms of intensity of care between the General Intensive Care Unit and the ordinary ward. In this article, the author analysed the cultural, scientific and organizational aspects of the central role played by the pulmonologist who's working in the RICU in the complex intra-hospital multi-disciplinary management of ARF.

Intensity of care and withdrawal of life-sustaining therapies in severe traumatic brain injury patients: a post-hoc analysis of a multicentre retrospective cohort study.

PubMed

Gerges, Peter R A; Moore, Lynne; Léger, Caroline; Lauzier, François; Shemilt, Michèle; Zarychanski, Ryan; Scales, Damon C; Burns, Karen E A; Bernard, Francis; Zygun, David; Neveu, Xavier; Turgeon, Alexis F

2018-06-14

The intensity of care provided to critically ill patients has been shown to be associated with mortality. In patients with traumatic brain injury (TBI), specialized neurocritical care is often required, but whether it affects clinically significant outcomes is unknown. We aimed to determine the association of the intensity of care on mortality and the incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI. We conducted a post hoc analysis of a multicentre retrospective cohort study of critically ill adult patients with severe TBI. We defined the intensity of care as a daily cumulative sum of interventions during the intensive care unit stay. Our outcome measures were all-cause hospital mortality and the incidence of withdrawal of life-sustaining therapies. Seven hundred sixteen severe TBI patients were included in our study. Most were male (77%) with a mean (standard deviation) age of 42 (20.5) yr and a median [interquartile range] Glasgow Coma Scale score of 3 [3-6]. Our results showed an association between the intensity of care and mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.63 to 0.74) and the incidence of withdrawal of life-sustaining therapy (HR, 0.73; 95% CI, 0.67 to 0.79). In general, more intense care was associated with fewer deaths and a lower incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI.

End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine.

PubMed

Myburgh, John; Abillama, Fayez; Chiumello, Davide; Dobb, Geoff; Jacobe, Stephen; Kleinpell, Ruth; Koh, Younsuk; Martin, Claudio; Michalsen, Andej; Pelosi, Paolo; Torra, Lluis Blanch; Vincent, Jean-Louis; Yeager, Susan; Zimmerman, Janice

2016-08-01

End-of-life care in the intensive care unit (ICU) was identified as an objective in a series of Task Forces developed by the World Federation of Societies of Intensive and Critical Care Medicine Council in 2014. The objective was to develop a generic statement about current knowledge and to identify challenges relevant to the global community that may inform regional and local initiatives. An updated summary of published statements on end-of-life care in the ICU from national Societies is presented, highlighting commonalities and differences within and between international regions. The complexity of end-of-life care in the ICU, particularly relating to withholding and withdrawing life-sustaining treatment while ensuring the alleviation of suffering, within different ethical and cultural environments is recognized. Although no single statement can therefore be regarded as a criterion standard applicable to all countries and societies, the World Federation of Societies of Intensive and Critical Care Medicine endorses and encourages the role of Member Societies to lead the debate regarding end-of-life care in the ICU within each country and to take a leading role in developing national guidelines and recommendations within each country. Copyright © 2016 Elsevier Inc. All rights reserved.

Bringing quality improvement into the intensive care unit.

PubMed

McMillan, Tracy R; Hyzy, Robert C

2007-02-01

During the last several years, many governmental and nongovernmental organizations have championed the application of the principles of quality improvement to the practice of medicine, particularly in the area of critical care. To review the breadth of approaches to quality improvement in the intensive care unit, including measures such as mortality and length of stay, and the use of protocols, bundles, and the role of large, multiple-hospital collaboratives. Several agencies have participated in the application of the quality movement to medicine, culminating in the development of standards such as the intensive care unit core measures of the Joint Commission on Accreditation of Healthcare Organizations. Although "zero defects" may not be possible in all measurable variables of quality in the intensive care unit, several measures, such as catheter-related bloodstream infections, can be significantly reduced through the implementation of improved processes of care, such as care bundles. Large, multiple-center, quality improvement collaboratives, such as the Michigan Keystone Intensive Care Unit Project, may be particularly effective in improving the quality of care by creating a "bandwagon effect" within a geographic region. The quality revolution is having a significant effect in the critical care unit and is likely to be facilitated by the transition to the electronic medical record.

Intensity of interprofessional collaboration among intensive care nurses at a tertiary hospital.

PubMed

Serrano-Gemes, G; Rich-Ruiz, M

To measure the intensity of interprofessional collaboration (IPC) in nurses of an intensive care unit (ICU) at a tertiary hospital, to check differences between the dimensions of the Intensity of Interprofessional Collaboration Questionnaire, and to identify the influence of personal variables. A cross-sectional descriptive study was conducted with 63 intensive care nurses selected by simple random sampling. Explanatory variables: age, sex, years of experience in nursing, years of experience in critical care, workday type and work shift type; variable of outcome: IPC. The IPC was measured by: Intensity of Interprofessional Collaboration Questionnaire. Descriptive and bivariate statistical analysis (IPC and its dimensions with explanatory variables). 73.8% were women, with a mean age of 46.54 (±6.076) years. The average years experience in nursing and critical care was 23.03 (±6.24) and 14.25 (±8.532), respectively. 77% had a full time and 95.1% had a rotating shift. 62.3% obtained average IPC values. Statistically significant differences were found (P<.05) between IPC (overall score) and overall assessment with years of experience in critical care. This study shows average levels of IPC; the nurses with less experience in critical care obtained higher IPC and overall assessment scores. Copyright © 2016 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.

[Cases of acute poisoning admitted to a medical intensive care unit].

PubMed

Viertel, A; Weidmann, E; Brodt, H R

2001-10-19

Because of the paucity of information on the epidemiology of acute poisoning requiring intensive medical care, all such patients treated on the medical intensive care unit of the university hospital in Frankfurt am Main, Germany, between January 1993 and December 1999, were retrospectively evaluated. Of the total of 6211 patients, 147 (80 women, 67 men, mean age 41 years, 2,3 %) were treated for acute intoxication in the intensive care unit. Reasons for admission to the intensive care unit were the need for ventilator treatment or intensive monitoring of vital functions. 52 % of the patients (n = 76) had attempted suicide, most of them using anti-depressive drugs (n = 19), paracetamol (n = 16), or benzodiazepines (n = 9). Two patients (2,6 %) died. 48 % of the patients (n = 71) were admitted because of accidental poisoning. Leading toxic agents in this group were heroin (n = 19), alcohol (n = 18) and digitalis (n = 12). 11 patients had taken herbicides, animal poisons or chemicals used at work or for house cleaning. In this cohort, three i. v. drug abusers (4,2 %) had died. Depending on the agents used, a variety of treatments (charcoal, antidots, extracorporal therapy) were undertaken. Due to excellent care in the prehospital phase and in the emergency room the number of patients requiring treatment on the intensive care unit was rather low. The mortality was in the range of other reports.

Use of active noise cancellation devices in caregivers in the intensive care unit.

PubMed

Akhtar, S; Weigle, C G; Cheng, E Y; Toohill, R; Berens, R J

2000-04-01

Recent development of noise cancellation devices may offer relief from noise in the intensive care unit environment. This study was conducted to evaluate the effect of noise cancellation devices on subjective hearing assessment by caregivers in the intensive care units. Randomized, double-blind. Adult medical intensive care unit and pediatric intensive care unit of a teaching hospital. Caregivers of patients, including nurses, parents, respiratory therapists, and nursing assistants from a medical intensive care unit and pediatric intensive care, were enrolled in the study. Each participant was asked to wear the headphones, functional or nonfunctional noise cancellation devices, for a minimum of 30 mins. Subjective ambient noise level was assessed on a 10-point visual analog scale (VAS) before and during headphone use by each participant. Headphone comfort and the preference of the caregiver to wear the headphone were also evaluated on a 10-point VAS. Simultaneously, objective measurement of noise was done with a sound level meter using the decibel-A scale and at each of nine octave bands at each bedspace. The functional headphones significantly reduced the subjective assessment of noise by 2 (out of 10) VAS points (p < 0.05) in environments of equal objective noise profiles, based on decibel-A and octave band assessments. Noise cancellation devices improve subjective assessment of noise in caretakers. The benefit of these devices on hearing loss needs further evaluation in caregivers and critically ill patients.

Evaluation of a Progressive Mobility Protocol in Postoperative Cardiothoracic Surgical Patients.

PubMed

Floyd, Shawn; Craig, Sarah W; Topley, Darla; Tullmann, Dorothy

2016-01-01

Cardiothoracic surgical patients are at high risk for complications related to immobility, such as increased intensive care and hospital length of stay, intensive care unit readmission, pressure ulcer development, and deep vein thrombosis/pulmonary embolus. A progressive mobility protocol was started in the thoracic cardiovascular intensive care unit in a rural academic medical center. The purpose of the progressive mobility protocol was to increase mobilization of postoperative patients and decrease complications related to immobility in this unique patient population. A matched-pairs design was used to compare a randomly selected sample of the preintervention group (n = 30) to a matched postintervention group (n = 30). The analysis compared outcomes including intensive care unit and hospital length of stay, intensive care unit readmission occurrence, pressure ulcer prevalence, and deep vein thrombosis/pulmonary embolism prevalence between the 2 groups. Although this comparison does not achieve statistical significance (P < .05) for any of the outcomes measured, it does show clinical significance in a reduction in hospital length of stay, intensive care unit days, in intensive care unit readmission rate, and a decline in pressure ulcer prevalence, which is the overall goal of progressive mobility. This study has implications for nursing, hospital administration, and therapy services with regard to staffing and cost savings related to fewer complications of immobility. Future studies with a larger sample size and other populations are warranted.

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review.

PubMed

Guilhermino, Michelle C; Inder, Kerry J; Sundin, Deborah

2018-03-26

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes. The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes. Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity. Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay. Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required. Well-designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes. © 2018 British Association of Critical Care Nurses.

Educational Intervention on Delirium Assessment Using Confusion Assessment Method-ICU (CAM-ICU) in a General Intensive Care Unit.

PubMed

Ramoo, Vimala; Abu, Harlinna; Rai, Vineya; Surat Singh, Surindar Kaur; Baharudin, Ayuni Asma'; Danaee, Mahmoud; Thinagaran, Raveena Rajalachimi R

2018-05-18

The primary objective was to assess intensive care unit nurses' knowledge of intensive care unit delirium and delirium assessment before and after an educational intervention. In addition, nurses' perception on the usefulness of a delirium assessment tool and barriers against delirium assessment were assessed as secondary objectives. Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools. This study, performed in Malaysia, used a single group pretest-posttest study design to assess the effect of educational interventions and hands-on practices on nurses' knowledge of intensive care unit delirium and delirium assessment. Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations, and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and post-intervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance. There were significant differences in the knowledge scores pre- and post-intervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were "physicians did not use nurses' delirium assessment in decision making" and "difficult to interpret delirium in intubated patients". Educational intervention and hands-on practices increased nurses' knowledge of delirium assessment. Teaching and inter-professional involvements are essential for a successful implementation of intensive care unit delirium assessment practice. This study supports existing evidences, indicating that education and training could increase nurses' knowledge of delirium and delirium assessment. Improving nurses' knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses' knowledge become relevant in ICU settings. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

[The future of intensive medicine].

PubMed

Palencia Herrejón, E; González Díaz, G; Mancebo Cortés, J

2011-05-01

Although Intensive Care Medicine is a young specialty compared with other medical disciplines, it currently plays a key role in the process of care for many patients. Experience has shown that professionals with specific training in Intensive Care Medicine are needed to provide high quality care to critically ill patients. In Europe, important steps have been taken towards the standardization of training programs of the different member states. However, it is now necessary to take one more step forward, that is, the creation of a primary specialty in Intensive Care Medicine. Care of the critically ill needs to be led by specialists who have received specific and complete training and who have the necessary professional competences to provide maximum quality care to their patients. The future of the specialty presents challenges that must be faced with determination, with the main objective of meeting the needs of the population. Copyright © 2011 Elsevier España, S.L. y SEMICYUC. All rights reserved.