Exploration of difficulty accessing the mouths of intubated and mechanically ventilated adults for oral care: A video and photographic elicitation study.

AIM: To explore descriptors of difficulty accessing the mouths of intubated and mechanically ventilated adults for oral care, consequences, modifiable antecedents and recommendations for improving care delivery. BACKGROUND: Nurses report oral access and care delivery difficulty in most mechanically ventilated patients. DESIGN: A prospective qualitative descriptive design. METHODS: Data were collected using video and photographic elicitation interviews focused on delivery of oral care. Directed content analysis was used to explore descriptive categories. Reporting used the SRQR guidelines. SETTING AND PARTICIPANTS: A university-affiliated hospital in Toronto, Canada. Participants included clinicians experienced in accessing the oral space of adults representing nursing, medicine, dentistry and allied health professionals. FINDINGS: We recruited 18 participants; 9 representing critical care and 9 other specialties frequently accessing the mouth, that is dentistry. Descriptors for observed difficulty accessing the oral cavity were "oral crowding with tubes" and "aversive patient responses", which were considered to result in insufficient oral care. Participants perceived aversive patient responses (e.g. biting, turning head side to side, gagging, coughing) as a consequence of forced introduction of instruments inside a crowded mouth. A key finding identified by participants was the observation of substantial procedural pain during oral care interventions. Potentially modifiable antecedents to difficult oral care delivery identified were procedural pain, oral health deterioration (e.g. xerostomia) and lack of interprofessional team problem-solving. Recommendations to address these antecedents included patient preparation for oral care through verbal and nonverbal cueing, pharmacological and nonpharmacological strategies, and ICU interprofessional education. CONCLUSIONS: Oral care in mechanically ventilated adults is complex and painful. Visual research methods offer important advantages for oral care exploration including its ability to reveal less visible aspects of the nurse-patient encounter, thereby enabling novel insights and care. RELEVANCE FOR CLINICAL PRACTICE: Interprofessional education and training in oral health and care interventions tailored to mechanically ventilated patients are recommended.

The Randomized Educational Acute Respiratory Distress Syndrome Diagnosis Study: A Trial to Improve the Radiographic Diagnosis of Acute Respiratory Distress Syndrome.

OBJECTIVES: Radiographic criteria for acute respiratory distress syndrome have been criticized for poor reliability. Our objective was to test an educational intervention to improve the radiographic identification of acute respiratory distress syndrome by participants in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure study. DESIGN: Randomized controlled trial. SETTINGS: Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure study centers. SUBJECTS: Study coordinators in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure study. INTERVENTIONS: Participants were randomized to either an online training module followed by a test module (intervention) or test module followed by training module (control). MEASUREMENTS AND MAIN RESULTS: The primary outcome was the number of radiographs correctly identified as meeting criteria for acute respiratory distress syndrome on an online test module (out of 11). Prespecified secondary analyses included a comparison of agreement between the groups and subgroup analyses by profession, age, years of experience, and stated familiarity with diagnostic criteria for acute respiratory distress syndrome. Four-hundred sixty-three study participants consented to participate. There was no effect of the intervention on correct answers by participants (proportion correct 58% [intervention] vs 56% [control]; p = 0.15), or in any subgroup analyses. Overall agreement between raters was 0.296 for the intervention and 0.272 for the control (p < 0.001). CONCLUSIONS: Participant recognition of radiographic criteria for acute respiratory distress syndrome was low, with poor agreement. This was not impacted by an educational intervention designed to improve accuracy of identification of radiographic criteria for acute respiratory distress syndrome.

"It's better to have three brains working instead of one": a qualitative study of building therapeutic alliance with family members of critically ill patients.

BACKGROUND: Studies in the intensive care unit (ICU) suggest that better communication between families of critically ill patients and healthcare providers is needed; however, most randomized trials targeting interventions to improve communication have failed to achieve family-centered outcomes. We aim to offer a novel analysis of the complexities involved in building positive family-provider relationships in the ICU through the consideration of not only communication but other important aspects of family-provider interactions, including family integration, collaboration, and empowerment. Our goal is to explore family members' perspectives on the enablers and challenges to establishing therapeutic alliance with ICU physicians and nurses. METHODS: We used the concept of therapeutic alliance as an organizational and analytic tool to conduct an interview-based qualitative study in a 20-bed adult medical-surgical ICU in an academic hospital in Toronto, Canada. Nineteen family members of critically ill patients who acted as substitute decision-makers and/or regularly interacted with ICU providers were interviewed. Participants were sampled purposefully to ensure maximum variation along predetermined criteria. A hybrid inductive-deductive approach to analysis was used. RESULTS: Participating family members highlighted the complementary roles and practices of ICU nurses and physicians in building therapeutic alliance. They reported how both provider groups had profession specific and shared contributions to foster family communication, integration, and collaboration, while physicians played a key role in family empowerment. Families' lack of familiarity with ICU personnel and processes, physicians' sporadic availability and use of medical jargon during rounds, however, reinforced long established power differences between lay families and expert physicians and challenged family integration. Family members also identified informal interactions as missed opportunities for relationship-building with physicians. While informal interactions with nurses at the bedside facilitated therapeutic alliance, inconsistent and ad-hoc interactions related to routine decision-making hindered family empowerment. CONCLUSIONS: Multiple opportunities exist to improve family-provider relationships in the ICU. The four dimensions of therapeutic alliance prove analytically useful to highlight those aspects that work well and need improvement, such as in the areas of family integration and empowerment.

Videos in clinical medicine. Insertion of an intraosseous needle in adults.

Intraosseous needle insertion is used as a temporary measure when intravascular access cannot be achieved through peripheral or central venous routes. The intraosseous needle may remain in situ for 72 to 96 hours, but it is best removed within 6 to 12 hours, as soon as an alternative site of intravascular access has been established. The intraosseous route provides fast and reliable vascular access in emergency medical situations. The use of the appropriate technique will ensure that the procedure is performed as safely and effectively as possible.

Standardized patient simulation versus didactic teaching alone for improving residents' communication skills when discussing goals of care and resuscitation: A randomized controlled trial.

BACKGROUND: Communication skills are important when discussing goals of care and resuscitation. Few studies have evaluated the effectiveness of standardized patients for teaching medical trainees to communicate about goals of care. OBJECTIVE: To determine whether standardized patient simulation offers benefit over didactic sessions alone for improving skill and comfort discussing goals of care. DESIGN AND INTERVENTION: Single-blind, randomized, controlled trial of didactic teaching plus standardized patient simulation versus didactic teaching alone. PARTICIPANTS: First-year internal medicine residents. MAIN MEASURES: Changes in communication comfort and skill between baseline and 2 months post-training assessed using the Consultation and Relational Empathy measure. KEY RESULTS: We enrolled 94 residents over a 2-year period. Both groups reported a significant improvement in comfort when discussing goals of care with patients. There was no difference in Consultation and Relational Empathy scores following the workshop ( p = 0.79). The intervention group showed a significant increase in Consultation and Relational Empathy scores post-workshop compared with pre-workshop (35.0 vs 31.7, respectively; p = 0.048), whereas there was no improvement in Consultation and Relational Empathy scores in the control group (35.6 vs 36.0; p = 0.4). However, when the results were adjusted for baseline differences in Consultation and Relational Empathy scores in a multivariable regression analysis, group assignment was not associated with an improvement in Consultation and Relational Empathy score. Improvement in comfort scores and perception of benefit were not associated with improvements in Consultation and Relational Empathy scores. CONCLUSION: Simulation training may improve communication skill and comfort more than didactic training alone, but there were important confounders in this study and further studies are needed to determine whether simulation is better than didactic training for this purpose.

An Online Training Program to Improve Clinicians' Skills in Communicating About Serious Illness.

BACKGROUND: Large-scale efforts to train clinicians in serious-illness communication skills are needed, but 2 important gaps in knowledge remain. (1) No proven training method exists that can be readily scaled to train thousands of clinicians. (2) Though the value of interprofessional collaboration to support incapacitated patients' surrogates is increasingly recognized, few interventions for training intensive care unit (ICU) nurses in important communication skills can be leveraged to provide interprofessional family support. OBJECTIVE: To develop and test a web/videoconference-based platform to train nurses to communicate about serious illness. METHODS: A user-centered process was used to develop the intervention, including (1) iteratively engaging a stakeholder panel, (2) developing prototype and beta versions of the platform, and (3) 3 rounds of user testing with 13 ICU nurses. Participants' ratings of usability, acceptability, and perceived effectiveness were assessed quantitatively and qualitatively. RESULTS: Stakeholders stressed that the intervention should leverage interactive learning and a streamlined digital interface. A training platform was developed consisting of 6 interactive online training lessons and 3 group-based video-conference practice sessions. Participants rated the program as usable (mean summary score 84 [96th percentile]), acceptable (mean, 4.5/5; SD, 0.7), and effective (mean, 4.8/5; SD, 0.6). Ten of 13 nurses would recommend the intervention over 2-day in-person training. CONCLUSIONS: Nurses testing this web-based training program judged it usable, acceptable, and effective. These data support proceeding with an appropriately powered efficacy trial.

Trends in site of death and health care utilization at the end of life: a population-based cohort study.

BACKGROUND: High rates of health care utilization at the end of life may be a marker of care that does not align with patient-stated preferences. We sought to describe trends in end-of-life care and factors associated with dying in hospital. METHODS: We conducted a population-level retrospective cohort study of adult decedents in Ontario between Apr. 1, 2004, and Mar. 31, 2015, using linked administrative data sets, including the Office of the Registrar General for Deaths database, the hospital Discharge Abstract Database, the National Ambulatory Care Reporting System and physicians' billing claims (Ontario Health Insurance Plan). The primary outcome was place of death. To determine health care utilization and health care costs during the 6 months before death, we also identified admissions to hospital and to the intensive care unit, emergency department visits, and receipt of mechanical ventilation and palliative care. RESULTS: In the last 6 months of life, 77.3% of 962 462 decedents presented to an emergency department, 68.4% were admitted to hospital, 19.4% were admitted to an intensive care unit, and 13.9% received mechanical ventilation. Forty-five percent of all deaths occurred in hospital, a proportion that declined marginally over time, whereas receipt of palliative care increased during terminal hospital admissions (from 14.0% in fiscal year 2004/05 to 29.3% in 2014/15, p < 0.001) and in the last 6 months of life (from 28.1% in 2004/05 to 57.7% in 2014/15, p < 0.001). The proportion of decedents who presented to the emergency department, were admitted to hospital or were admitted to the intensive care unit in the last 6 months of life did not change over 11 years. The mean total health care costs in the last 6 months of life were highest among those dying in hospital, with most costs attributable to inpatient medical care. INTERPRETATION: Health care utilization in the last 6 months of life was substantial and did not decrease over time. It is possible that increased capacity for palliative, hospice and home care at the end of life may help to better align health system resources with the preferences of most patients, a topic that should be explored in future studies.

A Peer-Reviewed Instructional Video is as Effective as a Standard Recorded Didactic Lecture in Medical Trainees Performing Chest Tube Insertion: A Randomized Control Trial.

OBJECTIVE: Online medical education resources are becoming an increasingly used modality and many studies have demonstrated their efficacy in procedural instruction. This study sought to determine whether a standardized online procedural video is as effective as a standard recorded didactic teaching session for chest tube insertion. DESIGN: A randomized control trial was conducted. Participants were taught how to insert a chest tube with either a recorded didactic teaching session, or a New England Journal of Medicine (NEJM) video. Participants filled out a questionnaire before and after performing the procedure on a cadaver, which was filmed and assessed by 2 blinded evaluators using a standardized tool. SETTING: Western University, London, Ontario. Level of clinical care: institutional. PARTICIPANTS: A total of 30 fourth-year medical students from 2 graduating classes at the Schulich School of Medicine & Dentistry were screened for eligibility. Two students did not complete the study and were excluded. There were 13 students in the NEJM group, and 15 students in the didactic group. RESULTS: The NEJM group׳s average score was 45.2% (±9.56) on the prequestionnaire, 67.7% (±12.9) for the procedure, and 60.1% (±7.65) on the postquestionnaire. The didactic group׳s average score was 42.8% (±10.9) on the prequestionnaire, 73.7% (±9.90) for the procedure, and 46.5% (±7.46) on the postquestionnaire. There was no difference between the groups on the prequestionnaire (Δ + 2.4%; 95% CI: -5.16 to 9.99), or the procedure (Δ -6.0%; 95% CI: -14.6 to 2.65). The NEJM group had better scores on the postquestionnaire (Δ + 11.15%; 95% CI: 3.74-18.6). CONCLUSIONS: The NEJM video was as effective as video-recorded didactic training for teaching the knowledge and technical skills essential for chest tube insertion. Participants expressed high satisfaction with this modality. It may prove to be a helpful adjunct to standard instruction on the topic.