Interfacility Transport of Critically Ill Patients.

OBJECTIVES: To assess recent advances in interfacility critical care transport. DATA SOURCES: PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION: Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION: Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS: The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS: Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

OBJECTIVE: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. METHODS: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. RESULTS: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. CONCLUSIONS: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

The Kaiser Permanente Northern California Advance Alert Monitor Program: An Automated Early Warning System for Adults at Risk for In-Hospital Clinical Deterioration.

BACKGROUND: In-hospital deterioration among ward patients is associated with substantially increased adverse outcome rates. In 2013 Kaiser Permanente Northern California (KPNC) developed and implemented a predictive analytics-driven program, Advance Alert Monitor (AAM), to improve early detection and intervention for in-hospital deterioration. The AAM predictive model is designed to give clinicians 12 hours of lead time before clinical deterioration, permitting early detection and a patient goals-concordant response to prevent worsening. DESIGN OF THE AAM INTERVENTION: Across the 21 hospitals of the KPNC integrated health care delivery system, AAM analyzes electronic health record (EHR) data for patients in medical/surgical and telemetry units 24 hours a day, 7 days a week. Patients identified as high risk by the AAM algorithm trigger an alert for a regional team of experienced critical care virtual quality nurse consultants (VQNCs), who then cascade validated, actionable information to rapid response team (RRT) nurses at local hospitals. RRT nurses conduct bedside assessments of at-risk patients and formulate interdisciplinary clinical responses with hospital-based physicians, bedside nurses, and supportive care teams to ensure a well-defined escalation plan that includes clarification of the patients' goals of care. SUCCESS OF THE INTERVENTION: Since 2019 the AAM program has been implemented at all 21 KPNC hospitals. The use of predictive modeling embedded within the EHR to identify high-risk patients has produced the standardization of monitoring workflows, clinical rescue protocols, and coordination to ensure that care is consistent with patients' individual goals of care. An evaluation of the program, using a staggered deployment sequence over 19 hospitals, demonstrates that the AAM program is associated with statistically significant decreases in mortality (9.8% vs. 14.4%), hospital length of stay, and ICU length of stay. Statistical analyses estimated that more than 500 deaths were prevented each year with the AAM program. LESSONS LEARNED: Unlocking the potential of predictive modeling in the EHR is the first step toward realizing the promise of artificial intelligence/machine learning (AI/ML) to improve health outcomes. The AAM program leveraged predictive analytics to produce highly reliable care by identifying at-risk patients, preventing deterioration, and reducing adverse outcomes and can be used as a model for how clinical decision support and inpatient population management can effectively improve care.

Innovation and Technology: Electronic Intensive Care Unit Diaries.

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.

Implementing the SCCM Family-Centered Care Guidelines in Critical Care Nursing Practice.

Family-centered care is an important component of holistic nursing practice, particularly in critical care, where the impact on families of admitted patients can be physiologically and psychologically burdensome. Family-centered care guidelines, developed by an international group of nursing, medical, and academic experts for the American College of Critical Care Medicine/Society of Critical Care Medicine, explore the evidence base in 5 key areas of family-centered care. Evidence in each of the guideline areas is outlined and recommendations are made about how critical care nurses can use this information in family-centered care practice.