Team dynamics in a COVID-19 intensive care unit: A qualitative study.

BACKGROUND: During the COVID-19 pandemic, new intensive care units (ICUs) were created and clinicians were assigned or volunteered to work in these ICUs. These new ICU teams were newly formed and may have had varying practice styles which could affect team dynamics. The purpose of our qualitative descriptive study was to explore clinician perceptions of team dynamics in this newly formed ICU and specifically understand the challenges and potential improvements in this environment to guide future planning and preparedness in ICUs. METHODS: We conducted 14 semistructured one-on-one interviews with six nurses and eight physicians from a newly formed 36- to 50-bed medical ICU designed for COVID-19 patients in a teaching hospital. We purposively sampled and recruited ICU nurses, medical/surgical nurses, fellows, and attending physicians (with pulmonary/critical care and anaesthesia training) to participate. Participants were asked about team dynamics in the ICU, its challenges, and potential solutions. We then used a rapid analytic approach by first deductively categorising interview data into themes, based on our interview guide, to create a unique data summary for each interview. Then, these data were transferred to a matrix to compare data across all interviews and inductively analysed these data to provide deeper insights into team dynamics in ICUs. RESULTS: We identified two themes that impacted team dynamics positively (facilitator) and negatively (barrier): interpersonal factors (individual character traits and interactions among clinicians) and structural factors (unit-level factors affecting workflow, organisation, and administration). Clinicians had several suggestions to improve team dynamics (e.g., scheduling to ensure clinicians familiar with one another worked together, standardisation of care processes across teams, and disciplines). CONCLUSIONS: In a newly formed COVID ICU, interpersonal factors and structural factors impacted the team's ability to work together. Considering team dynamics during ICU reorganisation is crucial and requires thoughtful attention to interpersonal and structural factors.

Improving delivery of continuous renal replacement therapy: impact of a simulation-based educational intervention.

PURPOSE: To describe our experience with transitions in both nursing model and educational training program for delivery of continuous renal replacement therapy. There have been very few comparisons between different care and educational models, and the optimal approach remains uncertain. In particular, we evaluated our experience with introducing a simulation-based educational model. DESIGN: Prospective quality control observational study. SETTING: The ICU of a tertiary care pediatric referral center. PATIENTS: All patients undergoing CRRT between July 2007 through July 2010 were included. MEASUREMENTS AND MAIN RESULTS: We monitored CRRT filter life during a transition from a collaborative to critical care nursing model, and subsequently during a transition from a didactic education program to simulation-based training. During the study period, 80 patients underwent continuous renal replacement therapy with use of 343 filters. Process control charts demonstrated a significant increase in filter life and a decrease in unplanned filter changes. Both of these signals emerged at the same time and corresponded with the introduction of the simulation-based education program. Further statistical analysis showed that filter life improved from 42.5 hours (18.2-66.4 hr) during the didactic education program to 59.4 hours (22.2-76.4 hr) during the simulation-based education program (p = 0.008). This relationship persisted when excluding nonpreventable premature filter discontinuations and in a multivariate model that accounted for other potential influences on filter life. CONCLUSIONS: We report on the impact of transitioning between different educational programs for continuous renal replacement therapy, specifically with the introduction of a simulation-based approach. We observed a significant and sustained improvement in the delivery of continuous renal replacement therapy as demonstrated by a marked increase in filter lifespan.

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

OBJECTIVE: This study analyses patterns in reporting rates of medication errors, rates of medication errors with harm, and responses to the Safety Attitudes Questionnaire (SAQ), all in the context of four cultural and three system-level interventions for medication safety in an intensive care unit. METHODS: Over a period of 2.5 years (May 2007 to November 2009), seven overlapping interventions to improve medication safety and reporting were implemented: a poster tracking 'days since last medication error resulting in harm', a continuous slideshow showing performance metrics in the staff lounge, multiple didactic curricula, unit-wide emails summarising medication errors, computerised physician order entry, introduction of unit-based pharmacy technicians for medication delivery, and patient safety report form streamlining. The reporting rate of medication errors and errors with harm were analysed over time using statistical process control. SAQ responses were collected annually. RESULTS: Subsequent to the interventions, the reporting rate of medication errors increased 25%, from an average of 3.16 to 3.95 per 10,000 doses dispensed (p<0.09), while the rate of medication errors resulting in harm decreased 71%, from an average of 0.56 to 0.16 per 10,000 doses dispensed (p<0.01). The SAQ showed improvement in all 13 survey items related to medication safety, five of which were significant (p<0.05). CONCLUSION: Actively developing a transparent and positive safety culture at the unit level can improve medication safety. System-level mechanisms to promote medication safety are likely important factors that enable safety culture to translate into better outcomes, but may be independently ineffective in the face of poor safety culture.

Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit.

OBJECTIVE: Unplanned extubation (UEX) is a potentially serious complication of mechanical ventilation. Limited information is available regarding factors that contribute to UEXs and subsequent reintubation of children. We monitored UEXs in our pediatric intensive care unit (PICU) for a 5-year period to assess the incidence and patient conditions associated with UEX and to evaluate whether targeted interventions were associated with a reduced rate of UEXs. METHODS: Over a 5-year period, demographic and clinical information was collected prospectively on all patients who required an artificial airway while admitted to the PICU. Additional information was collected for patients who experienced an UEX. Educational sessions and care management protocols were developed, implemented, and modified according to issues identified via the monitoring program. RESULTS: From a total of 2192 patients who required 13 630 airway days (AWD), 141 (6%) patients experienced 164 UEXs. The overall rate of UEX for the study period was 1.2 UEXs per 100 AWD, and this rate decreased from 1.5 in the first year to 0.8 in the last year. UEXs were more common in children who were younger than 5 years (1.6 vs 0.6 UEX per 100 AWD) compared with older children. The UEX children experienced significantly longer length of mechanical ventilation (6 vs 3 days) and longer length of PICU stay (8 vs 4 days) compared with non-UEX children. Forty-six percent of the UEXs occurred in patients who were weaning from mechanical ventilation, and 22% of those patients required reintubation. CONCLUSIONS: We conclude that UEX in pediatric patients is associated with longer length of mechanical ventilation and length of stay in the PICU. A continuous quality improvement monitoring and educational program that identified high-risk patients for UEX (younger patients) and patients who were at low risk for subsequent reintubation (weaning patients) contributed to a reduction of these potentially adverse events.