Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study.

Rationale: Patients receiving prolonged mechanical ventilation experience low survival rates and incur high healthcare costs. However, little is known about how to optimally organize and manage their care.Objectives: To identify a set of effective care practices for patients receiving prolonged mechanical ventilation.Methods: We performed a focused ethnographic evaluation at eight long-term acute care hospitals in the United States ranking in either the lowest or highest quartile of risk-adjusted mortality in at least four of the five years between 2007 and 2011.Measurements and Main Results: We conducted 329 hours of direct observation, 196 interviews, and 39 episodes of job shadowing. Data were analyzed using thematic content analysis and a positive-negative deviance approach. We found that high- and low-performing hospitals differed substantially in their approach to care. High-performing hospitals actively promoted interdisciplinary communication and coordination using a range of organizational practices, including factors related to leadership (e.g., leaders who communicate a culture of quality improvement), staffing (e.g., lower nurse-to-patient ratios and ready availability of psychologists and spiritual care providers), care protocols (e.g., specific yet flexible respiratory therapy-driven weaning protocols), team meetings (e.g., interdisciplinary meetings that include direct care providers), and the physical plant (e.g., large workstations that allow groups to interact). These practices were believed to facilitate care that is simultaneously goal directed and responsive to individual patient needs, leading to more successful liberation from mechanical ventilation and improved survival.Conclusions: High-performing long-term acute care hospitals employ several organizational practices that may be helpful in improving care for patients receiving prolonged mechanical ventilation.

Determinants of Intensive Care Unit Telemedicine Effectiveness. An Ethnographic Study.

RATIONALE: Telemedicine is an increasingly common care delivery strategy in the ICU. However, ICU telemedicine programs vary widely in their clinical effectiveness, with some studies showing a large mortality benefit and others showing no benefit or even harm. OBJECTIVES: To identify the organizational factors associated with ICU telemedicine effectiveness. METHODS: We performed a focused ethnographic evaluation of 10 ICU telemedicine programs using site visits, interviews, and focus groups in both facilities providing remote care and the target ICUs. Programs were selected based on their change in risk-adjusted mortality after adoption (decreased mortality, no change in mortality, and increased mortality). We used a constant comparative approach to guide data collection and analysis. MEASUREMENTS AND MAIN RESULTS: We conducted 460 hours of direct observation, 222 interviews, and 18 focus groups across six telemedicine facilities and 10 target ICUs. Data analysis revealed three domains that influence ICU telemedicine effectiveness: 1) leadership (i.e., the decisions related to the role of the telemedicine, conflict resolution, and relationship building), 2) perceived value (i.e., expectations of availability and impact, staff satisfaction, and understanding of operations), and 3) organizational characteristics (i.e., staffing models, allowed involvement of the telemedicine unit, and new hire orientation). In the most effective telemedicine programs these factors led to services that are viewed as appropriate, integrated, responsive, and consistent. CONCLUSIONS: The effectiveness of ICU telemedicine programs may be influenced by several potentially modifiable factors within the domains of leadership, perceived value, and organizational structure.

Perceptions of rounding checklists in the intensive care unit: a qualitative study.

BACKGROUND: Rounding checklists are an increasingly common quality improvement tool in the intensive care unit (ICU). However, effectiveness studies have shown conflicting results. We sought to understand ICU providers' perceptions of checklists, as well as barriers and facilitators to effective utilisation of checklists during daily rounds. OBJECTIVES: To understand how ICU providers perceive rounding checklists and develop a framework for more effective rounding checklist implementation. METHODS: We performed a qualitative study in 32 ICUs within 14 hospitals in a large integrated health system in the USA. We used two complementary data collection methods: direct observation of daily rounds and semistructured interviews with ICU clinicians. Observations and interviews were thematically coded and primary themes were identified using a combined inductive and deductive approach. RESULTS: We conducted 89 interviews and performed 114 hours of observation. Among study ICUs, 12 used checklists and 20 did not. Participants described the purpose of rounding checklists as a daily reminder for evidence-based practices, a tool for increasing shared understanding of patient care across care providers and a way to increase the efficiency of rounds. Checklists were perceived as not helpful when viewed as overstandardising care and when they are not relevant to a particular ICU's needs. Strategies to improve checklist implementation include attention to the brevity and relevance of the checklist to the particular ICU, consistent use over time, and integration with daily work flow. CONCLUSION: Our results provide potential insights about why ICU rounding checklists frequently fail to improve outcomes and offer a framework for effective checklist implementation through greater feedback and accountability.