Barriers and Facilitators to End-of-Life Care Delivery in ICUs: A Qualitative Study.

OBJECTIVES: To understand frontline ICU clinician's perceptions of end-of-life care delivery in the ICU. DESIGN: Qualitative observational cross-sectional study. SETTING: Seven ICUs across three hospitals in an integrated academic health system. SUBJECTS: ICU clinicians (physicians [critical care, palliative care], advanced practice providers, nurses, social workers, chaplains). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 27 semi-structured interviews were conducted, recorded, and transcribed. The research team reviewed all transcripts inductively to develop a codebook. Thematic analysis was conducted through coding, category formulation, and sorting for data reduction to identify central themes. Deductive reasoning facilitated data category formulation and thematic structuring anchored on the Systems Engineering Initiative for Patient Safety model identified that work systems (people, environment, tools, tasks) lead to processes and outcomes. Four themes were barriers or facilitators to end-of-life care. First, work system barriers delayed end-of-life care communication among clinicians as well as between clinicians and families. For example, over-reliance on palliative care people in handling end-of-life discussions prevented timely end-of-life care discussions with families. Second, clinician-level variability existed in end-of-life communication tasks. For example, end-of-life care discussions varied greatly in process and outcomes depending on the clinician leading the conversation. Third, clinician-family-patient priorities or treatment goals were misaligned. Conversely, regular discussion and joint decisions facilitated higher familial confidence in end-of-life care delivery process. These detailed discussions between care teams aligned priorities and led to fewer situations where patients/families received conflicting information. Fourth, clinician moral distress occurred from providing nonbeneficial care. Interviewees reported standardized end-of-life care discussion process incorporated by the people in the work system including patient, family, and clinicians were foundational to delivering end-of-life care that reduced both patient and family suffering, as well as clinician moral distress. CONCLUSIONS: Standardized work system communication tasks may improve end-of life discussion processes between clinicians and families.

Implementation of point-of-care blood gas testing at a large community hospital: Cost analysis, sepsis bundle compliance, and employee engagement.

INTRODUCTION/BACKGROUND: Point-of-care testing (POCT) platforms support patient-centered approaches to health care delivery and may improve patient care. We evaluated implementation of a POCT platform at a large, acute care hospital in the Midwestern United States. METHODS: We used lactate testing as part of a sepsis bundle protocol to evaluate compliance and mortality outcomes. Respiratory team members were surveyed to assess perception of efficiency, ease of use, timely patient care, and overall engagement with the POCT system. Annualized cost per test of a benchtop analyzer and a POCT platform were compared across 3 years for each platform. RESULTS: Lactate testing volume increased from 61% to 91%, which was associated with improved sepsis bundle protocol compliance. Employees reported high levels of engagement, improvements in efficiency and time savings, and better patient care with POCT. Average cost per test was $10.02 for the benchtop system and $6.21 for the POCT platform. POCT saved our institution $88,476 annually in labor costs. DISCUSSION: Combined with a robust training program emphasizing the use of lactate testing in the context of the overall clinical picture, POCT enabled adherence to the sepsis bundle protocol and may have contributed to lower mortality. Additionally, the COVID-19 pandemic has provided us with unanticipated benefits of using POCT; it has enhanced our ability to deal with stringent infectious disease protocols, saving time and minimizing patient and staff exposure. CONCLUSIONS: Implementation of a POCT platform was associated with improved compliance to our sepsis protocol, reduced sepsis mortality, high employee engagement, and cost savings.

Evaluation of Safety and Cost of an Open-Design Oxygen Mask in a Large Community Hospital.

BACKGROUND: In our large community hospital, we observed that traditional oxygen masks were sometimes set at an inappropriately low flow. We hoped to eliminate this safety concern through adoption of an open-design oxygen mask. We also hoped that more immediate flow changes would lead to a decrease in medical gas consumption. Finally, by standardizing to one mask, goals were to reduce the cost of oxygen delivery. METHODS: We conducted a retrospective analysis, 12 months before and 12 months after implementation of the open-design oxygen mask. Unusual occurrence reports related to supplemental oxygen delivery were reviewed. Oxygen device use and bulk oxygen consumption were recorded. The total number of patient days was obtained from the electronic medical record. RESULTS: There were no unusual occurrence reports or concerns involving an oxygen device in those areas that converted to the open-design oxygen mask. In fiscal year 2014, bulk oxygen use was 13,036,686 cubic feet, and there were 74,734 patient days. In fiscal year 2016, bulk oxygen use was 12,072,610 cubic feet and there were 99,428 patient days. The reduction in oxygen consumption was $3,670 despite the increase in patient days. In fiscal year 2014, 3,848 oxygen devices were used for a cost of $3,411, and in fiscal year 2016, 5,512 devices were used for a cost of $12,963. The net savings from open-design oxygen mask conversion was $23,487 annual and corrected for increased patient population. Oxygen consumption and supply cost per patient day resulted in $1.19 per patient day pre-implementation and $0.95 after implementation of the open-design oxygen mask (P = .003). CONCLUSIONS: The open-design oxygen mask may be a safe and less costly alternative to traditional oxygen delivery devices.