Soothing the heart with music: A feasibility study of a bedside music therapy intervention for critically ill patients in an urban hospital setting.

OBJECTIVES: Music therapy has been shown to be effective for reducing anxiety and pain in people with a serious illness. Few studies have investigated the feasibility of integrating music therapy into general inpatient care of the seriously ill, including the care of diverse, multiethnic patients. This leaves a deficit in knowledge for intervention planning. This study investigated the feasibility and effectiveness of introducing music therapy for patients on 4 inpatient units in a large urban medical center. Capacitated and incapacitated patients on palliative care, transplantation, medical intensive care, and general medicine units received a single bedside session led by a music therapist. METHODS: A mixed-methods, pre-post design was used to assess clinical indicators and the acceptability and feasibility of the intervention. Multiple regression modeling was used to evaluate the effect of music therapy on anxiety, pain, pulse, and respiratory rate. Process evaluation data and qualitative analysis of observational data recorded by the music therapists were used to assess the feasibility of providing music therapy on the units and patients' interest, receptivity, and satisfaction. RESULTS: Music therapy was delivered to 150 patients over a 6-month period. Controlling for gender, age, and session length, regression modeling showed that patients reported reduced anxiety post-session. Music therapy was found to be an accessible and adaptable intervention, with patients expressing high interest, receptivity, and satisfaction. SIGNIFICANCE OF RESULTS: This study found it feasible and effective to introduce bedside music therapy for seriously ill patients in a large urban medical center. Lessons learned and recommendations for future investigation are discussed.

Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review.

OBJECTIVES: To assess-by literature review and expert consensus-workforce, workload, and burnout considerations among intensivists and advanced practice providers. DESIGN: Data were synthesized from monthly expert consensus and literature review. SETTING: Workforce and Workload section workgroup of the Academic Leaders in Critical Care Medicine Task Force. MEASUREMENTS AND MAIN RESULTS: Multidisciplinary care teams led by intensivists are an essential component of critical care delivery. Advanced practice providers (nurse practitioners and physician assistants) are progressively being integrated into ICU practice models. The ever-increasing number of patients with complex, life-threatening diseases, concentration of ICU beds in few centralized hospitals, expansion of specialty ICU services, and desire for 24/7 availability have contributed to growing intensivist staffing concerns. Such staffing challenges may negatively impact practitioner wellness, team perception of care quality, time available for teaching, and length of stay when the patient to intensivist ratio is greater than or equal to 15. Enhanced team communication and reduction of practice variation are important factors for improved patient outcomes. A diverse workforce adds value and enrichment to the overall work environment. Formal succession planning for ICU leaders is crucial to the success of critical care organizations. Implementation of a continuous 24/7 ICU coverage care model in high-acuity, high-volume centers should be based on patient-centered outcomes. High levels of burnout syndrome are common among intensivists. Prospective analyses of interventions to decrease burnout within the ICU setting are limited. However, organizational interventions are felt to be more effective than those directed at individuals. CONCLUSIONS: Critical care workforce and staffing models are myriad and based on several factors including local culture and resources, ICU organization, and strategies to reduce burden on the ICU provider workforce. Prospective studies to assess and avoid the burnout syndrome among intensivists and advanced practice providers are needed.

Critical Care Organizations: Business of Critical Care and Value/Performance Building.

OBJECTIVE: New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for value-based care. DESIGN: Relevant medical literature was accessed through a literature search. Material published by federal health agencies and other specialty organizations was also reviewed. Collaboratively and iteratively, taskforce members corresponded by electronic mail and held monthly conference calls to finalize this report. SETTING: The business and value/performance critical care organization building section comprised of leaders of critical care organizations with expertise in critical care administration, healthcare management, and clinical practice. MEASUREMENTS AND MAIN RESULTS: Two phases of critical care organizations care integration are described: "horizontal," within the system and regionalization of care as an initial phase, and "vertical," with a post-ICU and postacute care continuum as a succeeding phase. The tools required for the clinical and financial transformation are provided, including the essential prerequisites of forming a critical care organization; the manner in which a critical care organization can help manage transformational domains is considered. Lastly, how to achieve organizational health system support for critical care organization implementation is discussed. CONCLUSIONS: A critical care organization that incorporates functional clinical horizontal and vertical integration for ICU patients and survivors, aligns strategy and operations with those of the parent health system, and encompasses knowledge on finance and risk will be better positioned to succeed in the value-based world.

Critical Care Organizations: Building and Integrating Academic Programs.

OBJECTIVE: Academic medical centers in North America are expanding their missions from the traditional triad of patient care, research, and education to include the broader issue of healthcare delivery improvement. In recent years, integrated Critical Care Organizations have developed within academic centers to better meet the challenges of this broadening mission. The goal of this article was to provide interested administrators and intensivists with the proper resources, lines of communication, and organizational approach to accomplish integration and Critical Care Organization formation effectively. DESIGN: The Academic Critical Care Organization Building section workgroup of the taskforce established regular monthly conference calls to reach consensus on the development of a toolkit utilizing methods proven to advance the development of their own academic Critical Care Organizations. Relevant medical literature was reviewed by literature search. Materials from federal agencies and other national organizations were accessed through the Internet. SETTING: The Society of Critical Care Medicine convened a taskforce entitled "Academic Leaders in Critical Care Medicine" on February 22, 2016 at the 45th Critical Care Congress using the expertise of successful leaders of advanced governance Critical Care Organizations in North America to develop a toolkit for advancing Critical Care Organizations. MEASUREMENTS AND MAIN RESULTS: Key elements of an academic Critical Care Organization are outlined. The vital missions of multidisciplinary patient care, safety, and quality are linked to the research, education, and professional development missions that enhance the value of such organizations. Core features, benefits, barriers, and recommendations for integration of academic programs within Critical Care Organizations are described. Selected readings and resources to successfully implement the recommendations are provided. Communication with medical school and hospital leadership is discussed. CONCLUSIONS: We present the rationale for critical care programs to transition to integrated Critical Care Organizations within academic medical centers and provide recommendations and resources to facilitate this transition and foster Critical Care Organization effectiveness and future success.

Severe Burnout Is Common Among Critical Care Physician Assistants.

OBJECTIVES: To determine the prevalence of and risk factors for burnout among critical care medicine physician assistants. DESIGN: Online survey. SETTINGS: U.S. ICUs. SUBJECTS: Critical care medicine physician assistant members of the Society of Critical Care Medicine coupled with personal contacts. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used SurveyMonkey to query critical care medicine physician assistants on demographics and the full 22-question Maslach Burnout Inventory, a validated tool comprised of three subscales-emotional exhaustion, depersonalization, and achievement. Multivariate regression was performed to identify factors independently associated with severe burnout on at least one subscale and higher burnout scores on each subscale and the total inventory. From 431 critical care medicine physician assistants invited, 135 (31.3%) responded to the survey. Severe burnout was seen on at least one subscale in 55.6%-10% showed evidence of severe burnout on the "exhaustion" subscale, 44% on the "depersonalization" subscale, and 26% on the "achievement" subscale. After multivariable adjustment, caring for fewer patients per shift (odds ratio [95% CI]: 0.17 [0.05-0.57] for 1-5 vs 6-10 patients; p = 0.004) and rarely providing futile care (0.26 [0.07-0.95] vs providing futile care often; p = 0.041) were independently associated with having less severe burnout on at least one subscale. Those caring for 1-5 patients per shift and those providing futile care rarely also had a lower depersonalization scores; job satisfaction was independently associated with having less exhaustion, less depersonalization, a greater sense of personal achievement, and a lower overall burnout score. CONCLUSIONS: Severe burnout is common in critical care medicine physician assistants. Higher patient-to-critical care medicine physician assistant ratios and provision of futile care are risk factors for severe burnout.

Critical Care Organizations in Academic Medical Centers in North America: A Descriptive Report.

OBJECTIVES: With the exception of a few single-center descriptive reports, data on critical care organizations are relatively sparse. The objectives of our study were to determine the structure, governance, and experience to date of established critical care organizations in North American academic medical centers. DESIGN: A 46-item survey questionnaire was electronically distributed using Survey Monkey to the leadership of 27 identified critical care organizations in the United States and Canada between September 2014 and February 2015. A critical care organization had to be headed by a physician and have primary governance over the majority, if not all, of the ICUs in the medical center. MEASUREMENTS AND MAIN RESULTS: We received 24 responses (89%). The majority of the critical care organizations (83%) were called departments, centers, systems, or operations committees. Approximately two thirds of respondents were from larger (> 500 beds) urban institutions, and nearly 80% were primary university medical centers. On average, there were six ICUs per academic medical center with a mean of four ICUs under critical care organization governance. In these ICUs, intensivists were present in-house 24/7 in 49%; advanced practice providers in 63%; hospitalists in 21%; and telemedicine coverage in 14%. Nearly 60% of respondents indicated that they had a separate hospital budget to support data management and reporting, oversight of their ICUs, and rapid response teams. The transition from the traditional model of ICUs within departmentally controlled services or divisions to a critical care organization was described as gradual in 50% and complete in only 25%. Nearly 90% indicated that their critical care organization governance structure was either moderately or highly effective; a similar number suggested that their critical care organizations were evolving with increasing domain and financial control of the ICUs at their respective institutions. CONCLUSIONS: Our survey of the very few critical care organizations in North American academic medical centers showed that the governance models of critical care organizations vary and continue to evolve. Additional studies are warranted to improve our understanding of the factors that can foster the growth of critical care organizations and how they can be effective.

Critical care medicine in the United States: addressing the intensivist shortage and image of the specialty.

Intensivists are increasingly needed to care for the critically ill and manage ICUs as ICU beds, utilization, acuity of illness, complexity of care and costs continue to rise. However, there is a nationwide shortage of intensivists that has occurred despite years of well publicized warnings of an impending workforce crisis from specialty societies and the federal government. The magnitude of the intensivist shortfall, however, is difficult to determine because there are many perspectives of optimal ICU administration, patient coverage and intensivist availability and a lack of national data on intensivist practices. Nevertheless, the intensivist shortfall is quite real as evidenced by the alternative solutions that hospitals are deploying to provide care for their critically ill patients. In the midst of these manpower struggles, the critical care environment is dynamically changing and becoming more stressful. Severe hospital bed availability and fiscal constraints are forcing ICUs to alter their approaches to triage, throughput and unit staffing. National and local organizations are mandating that hospitals comply with resource intensive and arguably unproven initiatives to monitor and improve patient safety and quality, and informatics systems. Lastly, there is an ongoing sense of professional dissatisfaction among intensivists and a lack of public awareness that critical care medicine is even a distinct specialty. This article offers proposals to increase the adult intensivist workforce through expansion and enhancements of internal medicine based critical care training programs, incentives for recent graduates to enter the critical care medicine field, suggestions for improvements in the critical care profession and workplace to encourage senior intensivists to remain in the field, proactive marketing of critical care, and expanded engagement by the critical care societies in the challenges facing intensivists.

How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU?

BACKGROUND: Neurological patients have lower mortality and better outcomes when cared for in specialized neurointensive care units than in general ICUs. However, little is known about how the process of care differs between these types of units. METHODS: The Greater New York Hospital Association conducted a city-wide 24-h ICU prevalence survey on March 15th, 2007. Data was collected on all patients admitted to 143 ICUs in 69 different hospitals. RESULTS: Of 1,906 ICU patients surveyed, 231 had a primary neurological diagnosis. Of these, 52 (22%) were admitted to one of 9 neuro-ICU's in NY and 179 (78%) to a medical or surgical ICU. Neurological patients in neuro-ICUs were more likely to have been transferred from an outside hospital (37% vs. 11%, P < 0.0001). Hemorrhagic stroke was more frequent in neuro-ICUs (46% vs. 16%, P < 0.0001), whereas traumatic brain injury (2% vs. 24%, P < 0.0001) and ischemic stroke (0% vs. 19%, P = 0.001) were less common. Despite a lower rate of mechanical ventilation (39% vs. 50%, P = 0.15), ICU length of stay was longer in neuro-ICU patients (≥10 days, 40% vs. 17%, P < 0.0001). More neuro-ICU patients had undergone tracheostomy (35% vs. 15%, P = 0.04), invasive hemodynamic monitoring (40% vs. 20%, P = 0.002), and invasive intracranial pressure monitoring (29% vs. 9%, P < 0.001) than patients cared for in general ICUs. Intravenous sedation was less prevalent in neuro-ICUs (12% vs. 30%, P = 0.009) and more patients were receiving nutritional support compared to general ICUs (67% vs. 39%, P < 0.001). CONCLUSIONS: Neurological patients cared for in specialty neuro-ICUs underwent more invasive intracranial and hemodynamic monitoring, tracheostomy, and nutritional support, and received less IV sedation than patients in general ICUs. These differences in care may explain previously observed disparities in outcome between neurocritical care and general ICUs.

Barriers to ultrasound training in critical care medicine fellowships: a survey of program directors.

OBJECTIVE: Ultrasonography is an effective tool for making quick diagnoses and guiding therapeutic procedures. National organizations have advocated increasing the use of critical care ultrasonography. The purpose of this study was to investigate the prevalence of teaching of critical care ultrasonography in fellowship programs. In addition, we hoped to identify barriers to establishment of ultrasound training programs. DESIGN: All pulmonary/critical care and critical care medicine (CCM) program directors in the United States were invited to participate in an online survey. We asked respondents for demographic information about their programs and perceived barriers to training, as well as current training opportunities for their fellows in five aspects of critical care ultrasonography. A five-point Likert scale was used for survey answers. SETTING: Web-based survey. SUBJECTS: Pulmonary/critical care and CCM program directors in the United States. INTERVENTIONS: Web-based survey. MEASUREMENTS AND MAIN RESULTS: Ninety (66%) of 136 program directors responded. Ultrasonography training was offered by fellowship programs in the following areas: vascular access (98%), lung and pleural (74%), cardiac (55%), vascular diagnostic (33%), and abdominal (37%). Ninety-two percent of respondents agreed or strongly agreed that ultrasound training is useful, and 80% were interested in getting their fellows trained. Forty-one percent indicated that they lacked sufficient faculty trained in ultrasound use. Eighty-four percent agreed or strongly agreed that fellow turnover was an impediment to training. Forty-eight percent believed that cardiac echocardiography required a long training time. CONCLUSIONS: Although ultrasound training in vascular access was nearly universal, training in other aspects of ultrasound was less prevalent. We identified several barriers, including fellow turnover, insufficient faculty training, and perceived length of time required for echocardiography training.

Preliminary report of the integration of a palliative care team into an intensive care unit.

Nearly half of Americans who die in hospitals spend time in the intensive care unit (ICU) in the last 3 days of life. Minority patients who die in the ICU are less likely to formalize advance directives and surviving family members report lower satisfaction with the provision of information and sensitivity to their cultural traditions at the end-of-life. This is a descriptive report of a convenience sample of 157 consecutive patients served by a palliative care team which was integrated into the operations of an ICU at Montefiore Medical Center in the Bronx, New York, from August 2005 until August 2007. The team included an advance practice nurse (APN) and social worker. A separate case-control study was conducted comparing the length of hospital stay for persons who died in the ICU during the final 6 months of the project, prior to and post-palliative care consultation for 22 patients at the hospital campus where the project team was located versus 24 patients at the other campus. Pharmaco-economic data were evaluated for 22 persons who died with and 43 who died without a palliative care consultation at the intervention campus ICU to evaluate whether the project intervention was associated with an increase in the use of pain medications or alterations in the use of potentially non-beneficial life-prolonging treatments in persons dying in the ICU. Data was abstracted from the medical record with a standardized chart abstraction instrument by an unblinded research assistant. Interviews were conducted with a sample of family members and ICU nurses rating the quality of end-of-life care in the ICU with the Quality of Dying and Death in the ICU instrument (ICUQODD), and a family focus group was also conducted. Forty percent of patients were Caucasian, 35% were African American or Afro-Caribbean, 22% Hispanic and 3% were Asian or other. Exploration of the patients' and families' needs identified significant spiritual needs in 62.4% of cases. Education on the death process was provided to 85% of families by the project team. Twenty-nine percent of patients were disconnected from mechanical ventilators following consultation with the Palliative Care Service (PCS), 15.9% of patients discontinued the use of inotropic support, 15.3% stopped artificial nutrition, 6.4% stopped dialysis and 2.5% discontinued artificial hydration. Recommendations on pain management were made for 51% of the project's patients and symptom management for 52% of patients. The project was associated with an increase in the rate of the formalization of advance directives. Thirty-three percent of the patients who received PCS consultations had 'do not resuscitate' orders in place prior to consultation and 83.4% had 'do not resuscitate' orders after the intervention. The project team referred 80 (51%) of the project patients to hospice and 55 (35%) patients were enrolled on hospice, primarily at the medical center. The mean time from admission to palliative care consultation at the project site was 2.8 days versus 15.5 days at the other campus (p = 0.0184). Median survival times from admission to the medical center were not significantly different when stratified by palliative care consultation status: 12 days for the control group (95% CI 8-18) and 13.5 days for the intervention group (95% CI 8-20). Median charges for the use of opioid medications were higher (p = 0.01) for the intervention group but lower for use of laboratory (p = 0.004) and radiology tests (p = 0.027). We conclude that the integration of palliative care experts into the operation of critical care units is of benefit to patients, families and critical care clinicians. Preliminary evidence suggest that such models may be associated with improved quality of life, higher rates of formalization of advance directives and utilization of hospices, as well as lower use of certain non-beneficial life-prolonging treatments for critically ill patients who are at the end of life.

Integration of Palliative Care Advanced Practice Nurses Into Intensive Care Unit Teams.

BACKGROUND: Referrals to palliative care for patients at the end of life in the intensive care unit (ICU) often happen late in the ICU stay, if at all. The integration of a palliative medicine advanced practice nurse (APN) is one potential strategy for proactively identifying patients who could benefit from this service. OBJECTIVE: To evaluate the association between the integration of palliative medicine APNs into the routine operations of ICUs and hospital costs at 2 different institutions, Montefiore Medical Center (MMC) and Rush University Medical Center. METHODS: The association between collaborative palliative care consultation service programs and hospital costs per patient was evaluated for the 2 institutions. Hospital costs were compared for patients with and without a referral to palliative care using Mann-Whitney U tests. RESULTS: Hospital nonroom and board costs at the Weiler campus of MMC were significantly lower for patients with palliative care compared with those who did not receive palliative care (Median = US$6643 vs US$12 399, P < .001). Cost differences for ICU patients with and without palliative care at Rush University Medical Center were not significantly different. CONCLUSION: Our evaluation suggests that the integration of APNs into a palliative care team for case finding may be a promising strategy, but more work is needed to determine whether reductions in cost are significant.

Bioterrorism and critical care.

A bioterrorist attack of any kind has the potential to overwhelm a community and, indeed, in the case of smallpox, an entire nation. During such an attack the number of patients requiring hospitalization and specifically critical care is likely to be enormous. Intensivists will be at the forefront of this war and will play an important role in dealing with mass casualties in an attempt to heal the community. A high degree of suspicion and prompt recognition of an event will be required to contain it. Specific knowledge of the possible agents that can be used will be key in managing patients and in estimating the needs of a health care facility and community to deal with the future course of events. Intensivists play various roles aside from the delivery of critical care to the patient in the ICU. These roles include making triage decisions regarding the appropriate use of critical care beds (which automatically dictates how other non-ICU beds are used and managed) and serving as a team member of ethics committees (on such issues as dying, futility, and withdrawal of care). Indeed, intensivists are no strangers to disaster management and have served on the forefront of many. A biologic weapons attack, however, is likely to push this multidimensional nature of the intensivist to the maximum, because such an attack is likely to result in a more homogeneous critically ill population where the number of critical care staff and supplies to treat the victims may be limited. One hopes that such an event will not occur. Sadly, however the events of September 11, 2001, have only heightened the awareness of such a possibility.

Open bedside tracheotomy: impact on patient care and patient safety.

OBJECTIVES: Objectives were: 1) to evaluate the impact of open bedside tracheotomy (OBT) on patient care and 2) to determine whether OBT in the intensive care unit (ICU) is a safe, cost-effective procedure. STUDY DESIGN: Retrospective chart-based review. METHODS: A total of 163 consecutive adult patients in the medical or surgical ICU who underwent OBT by the Otorhinolaryngology service from July 2007 to July 2009, in addition to the 163 consecutive adult patients who had undergone open tracheotomy in the operating room immediately prior to July 2007, were included in the study. Data examined included time intervals between initial consultation and performance of tracheotomy, complication rates, ICU length of stay, and cost considerations. RESULTS: In the group of patients examined prior to OBT, time to surgery (TTS) averaged 3.24 days in comparison to an average of 1.48 days for patients who received OBT (P < .05). Review of complications revealed no significant difference in the two study groups (odds ratio [OR], 1.42, 95% confidence interval [CI], 0.44-4.56, P = .56). The length of ICU stay decreased by 0.6 days on average in the OBT group versus the OR group, although not achieving statistical significance (P = .18). Cost analysis suggests a potential savings of $4,575 per case, resulting in approximately $745,700 saved in the OBT group. CONCLUSIONS: Review of our experience demonstrates comparable safety for tracheotomy performed bedside versus in the operating room, while offering shorter time to surgery, decreased costs, and perhaps a reduction in the length of ICU stay. These findings suggest that open bedside tracheotomy is preferable to tracheotomy performed in the operating room for patients in the ICU setting.

Investigation of critical care unit utilization and mortality in patients infected with Clostridium difficile.

BACKGROUND: A nationwide increase in the rate and severity of Clostridium difficile-associated disease may reflect infection with a virulent strain characterized by polymerase chain reaction as ribotype 027 (NAP1/B1). HYPOTHESIS: The high prevalence of ribotype 027 at our institution would allow investigation of the risk of mortality and admission to the intensive care unit (ICU) associated with C difficile infection. METHODS: In a retrospective cohort study, we identified 108 patients with positive enzyme-linked immunosorbant assay tests for C difficile toxins over a 6-month period and compared them to 108 patients who were suspected to have C difficile but with negative toxin assays. Proportions of all-cause mortality and ICU admission were compared using chi(2), and odds ratios (ORs) were estimated using logistic regression to adjust for potential confounders. Mean log lengths of stay were compared using t test. RESULTS: Comparing patients with C difficile to those without, mortality (20% vs 8%) and ICU admission (32% vs 17%) were significantly higher (P = .02 for both), whereas log length of stay was not (P = .29). Adjusting for potential confounders, the OR for mortality was 6.8 (95% confidence interval, 1.8-25.4; P = .01), whereas for ICU admission, the association was no longer observed (OR, 1.0; 95% confidence interval, 0.4-2.5; P = .97). CONCLUSION: C difficile infection was associated with increased all-cause mortality. An observed association with ICU admission and C difficile infection was identified through univariate analysis but was not significant in multivariate analysis. Although we did not strain-type isolates for patients infected with C difficile, the institutional prevalence of ribotype 027 C difficile infection was known to be high. These results document a strong association between ribotype 027 C difficile infection and mortality and underscore the need to identify effective C difficile preventive strategies.