Hospital factors that influence ICU admission decision-making: a qualitative study of eight hospitals.

PURPOSE: Some hospitals in the United States (US) use intensive care 20 times more than others. Since intensive care is lifesaving for some but potentially harmful for others, there is a need to understand factors that influence how intensive care unit (ICU) admission decisions are made. METHODS: A qualitative analysis of eight US hospitals was conducted with semi-structured, one-on-one interviews supplemented by site visits and clinical observations. RESULTS: A total of 87 participants (24 nurses, 52 physicians, and 11 other staff) were interviewed, and 40 h were spent observing ICU operations across the eight hospitals. Four hospital-level factors were identified that influenced ICU admission decision-making. First, availability of intermediate care led to reallocation of patients who might otherwise be sent to an ICU. Second, participants stressed the importance of ICU nurse availability as a key modifier of ICU capacity. Patients cared for by experienced general care physicians and nurses were less likely to receive ICU care. Third, smaller or rural hospitals opted for longer emergency department patient-stays over ICU admission to expedite interhospital transfer of critically ill patients. Fourth, lack of clarity in ICU admission policies led clinicians to feel pressured to use ICU care for patients who might otherwise not have received it. CONCLUSION: Health care systems should evaluate their use of ICU care and establish institutional patterns that ensure ICU admission decisions are patient-centered but also account for resources and constraints particular to each hospital.

The Influence of the COVID-19 Pandemic on Intensivists' Well-Being: A Qualitative Study.

BACKGROUND: The COVID-19 pandemic has strained health care systems and has resulted in widespread critical care staffing shortages, negatively impacting the quality of care delivered. RESEARCH QUESTION: How have hospitals' emergency responses to the pandemic influenced the well-being of frontline intensivists, and do any potential strategies exist to improve their well-being and to help preserve the critical care workforce? STUDY DESIGN AND METHODS: We conducted semistructured interviews of intensivists at clusters of tertiary and community hospitals located in six regions across the United States between August and November 2020 using the "four S" framework of acute surge planning (ie, space, staff, stuff, and system) to organize the interview guide. We then used inductive thematic analysis to identify themes describing the influence of hospitals' emergency responses on intensivists' well-being. RESULTS: Thirty-three intensivists from seven tertiary and six community hospitals participated. Intensivists reported experiencing substantial moral distress, particularly because of restricted visitor policies and their perceived negative impacts on patients, families, and staff. Intensivists also frequently reported burnout symptoms as a result of their experiences with patient death, exhaustion over the pandemic's duration, and perceived lack of support from colleagues and hospitals. We identified several potentially modifiable factors perceived to improve morale, including the proactive provision of mental health resources, establishment of formal backup schedules for physicians, and clear actions demonstrating that clinicians are valued by their institutions. INTERPRETATION: Restrictive visitation policies contributed to moral distress as reported by intensivists, highlighting the need to reconsider the risks and benefits of these policies. We also identified several interventions as perceived by intensivists that may help to mitigate moral distress and to improve burnout as part of efforts to preserve the critical care workforce.

The Influence of the COVID-19 Pandemic on ICU Organization, Care Processes, and Frontline Clinician Experiences: A Qualitative Study.

BACKGROUND: The COVID-19 pandemic resulted in unprecedented adjustments to ICU organization and care processes globally. RESEARCH QUESTIONS: Did hospital emergency responses to the COVID-19 pandemic differ depending on hospital setting? Which strategies worked well to mitigate strain as perceived by intensivists? STUDY DESIGN AND METHODS: Between August and November 2020, we carried out semistructured interviews of intensivists from tertiary and community hospitals across six regions in the United States that experienced early or large surges of COVID-19 patients, or both. We identified themes of hospital emergency responses using the four S framework of acute surge planning: space, staff, stuff, system. RESULTS: Thirty-three intensivists from seven tertiary and six community hospitals participated. Clinicians across both settings believed that canceling elective surgeries was helpful to increase ICU capabilities and that hospitals should establish clearly defined thresholds at which surgeries are limited during future surge events. ICU staff was the most limited resource; staff shortages were improved by the use of tiered staffing models, just-in-time training for non-ICU clinicians, designated treatment teams, and deployment of trainees. Personal protective equipment (PPE) shortages and reuse were widespread, causing substantial distress among clinicians; hands-on PPE training was helpful to reduce clinicians' anxiety. Transparency and involvement of frontline clinicians as stakeholders were important components of effective emergency responses and helped to maintain trust among staff. INTERPRETATION: We identified several strategies potentially to mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrated the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.

Surgical treatment of femoroacetabular impingement: a systematic review of the literature.

UNLABELLED: The surgical treatment of femoroacetabular impingement has become more common, yet the strength of clinical evidence to support this surgery is debated. We performed a systematic review of the literature to (1) define the level of evidence regarding hip impingement surgery; (2) determine whether the surgery relieves pain and improves function; (3) identify the complications; and (4) identify modifiable causes of failure (conversion to total hip arthroplasty). We searched the literature between 1950 and 2009 for all studies reporting on surgical treatment of femoroacetabular impingement. Studies with clinical outcome data and minimum two year followup were analyzed. Eleven studies met our criteria for inclusion. Nine were Level IV and two were Level III. Mean followup was 3.2 years; range (2-5.2 years). Reduced pain and improvement in hip function were reported in all studies. Conversion to THA was reported in 0% to 26% of cases. Major complications occurred in 0% to 18% of the procedures. Current evidence regarding femoroacetabular impingement surgery is primarily Level IV and suggests the various surgical techniques are associated with pain relief and improved function in 68-96% of patients over short-term followup. Long-term followup is needed to determine survivorship and impact on osteoarthritis progression and natural history. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Combined periacetabular and femoral osteotomies for severe hip deformities.

Periacetabular osteotomy (PAO) is an effective acetabular reorientation technique for treatment of symptomatic acetabular dysplasia. In hips with severe deformities, an adjunctive femoral osteotomy (PFO) may optimize correction, joint stability, and congruency. We analyzed the clinical and radiographic results of combined PAO/PFO in treating severe hip deformities. Second, we compared the clinical results of patients treated with PAO/PFO with patients treated with isolated PAO for lesser deformities. Twenty-five patients (28 hips) treated with PAO/PFO were reviewed and followed a minimum of 16 months (mean, 44 months). The matched PAO cohort included 25 patients (28 hips). For the PAO/PFO group, the average Harris hip score improved from 60.9 to 86.3. Eighty-nine percent of the patients demonstrated at least a 10-point improvement in the hip score and 75% had a Harris hip score over 80 points. Radiographic evaluation demonstrated consistent deformity correction. The PAO/PFO group had a lower average Harris hip score preoperatively, yet hip function after surgery was comparable between groups. These data indicate combined PAO/PFO is associated with improved hip function in most patients. These clinical results are comparable to those obtained with isolated PAO for lesser hip deformities.

Periacetabular osteotomy: a systematic literature review.

UNLABELLED: The Bernese periacetabular osteotomy is commonly used to treat symptomatic acetabular dysplasia. Although periacetabular osteotomy is becoming a more common surgical intervention to relieve pain and improve function, the strength of clinical evidence to support this procedure for these goals is not well defined in the literature. We therefore performed a systematic review of the literature to define the level of evidence for periacetabular osteotomy, to determine deformity correction, clinical results, and to determine complications associated with the procedure. Thirteen studies met our inclusion criteria. Eleven studies were Level IV, one was Level III, and one was Level II. Radiographic deformity correction was consistent and improvement in hip function was noted in all studies. Most studies did not correlate radiographic and clinic outcomes. Clinical failures were commonly associated with moderate to severe preoperative osteoarthritis and conversion to THA was reported in 0% to 17% of cases. Major complications were noted in 6% to 37% of the procedures. These data indicate periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm followup. The current evidence is primarily Level IV. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Development of a patient safety culture measurement tool for ambulatory health care settings: analysis of content validity.

The development of patient safety culture in health care organizations is a necessary precursor to patient safety improvement. However, existing tools to measure patient safety culture are intended for implementation in hospitals. A new, abbreviated patient safety culture survey was developed for use in ambulatory health care settings. This survey was tested for content validity utilizing a panel of six experts. It had a clarity interrater agreement (IR) of 0.75, a clarity content validity index (CVI) of 0.95, a representativeness IR of 0.75 and a representativeness CVI of 0.95. The content validity analysis served as a useful tool for assessing the relevance and comprehensiveness of this survey of patient safety culture in ambulatory care organizations.