Resting Energy Expenditure of Patients on Venovenous Extracorporeal Membrane Oxygenation for Adult Respiratory Distress Syndrome: A Pilot Study.

OBJECTIVES: The objectives of this study were to 1) in patients without pulmonary function, determine resting energy expenditure (REE) in venovenous extracorporeal membrane oxygenation (ECMO) acute respiratory distress syndrome (ARDS) patients by paralysis status and 2) determine the threshold tidal volume (TV) associated with meaningful gas exchange as determined by measurable end-tidal carbon dioxide elimination (etV̇co2). DESIGN: Retrospective observational study. SETTING: A tertiary high ECMO volume academic institution. PATIENTS/SUBJECTS: Ten adult ARDS patients on venovenous ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The modified Weir equation, Fick principle, Henderson-Hasselbalch equation, ECMO flow, hemoglobin, and pre and post oxygenator blood gases were used to determine ECMO carbon dioxide production (V̇co2), ECMO oxygen consumption, and REE. REE values were matched to patients' paralysis status based on medication flowsheets and compared using a paired t test. Linear regression was performed to determine the threshold TV normalized to ideal body weight (IBW) associated with measurable ventilator etV̇co2, above which meaningful ventilation occurs. When lungs were not functioning, patients had significantly lower mean REE when paralyzed (23.4 ± 2.8 kcal/kg/d) than when not paralyzed (29.2 ± 5.8 kcal/kg/d) (p = 0.02). Furthermore, mean REE was not similar between patients and varied as much as 1.7 times between patients when paralyzed and as much as 1.4 times when not paralyzed. Linear regression showed that ventilator V̇co2 was measurable and increased linearly when TV was greater than or equal to 0.7 mL/kg. CONCLUSIONS: REE is patient-specific and varies significantly with and without patient paralysis. When TV exceeds 0.7 mL/kg IBW, ventilator V̇co2 increases measurably and must be considered in determining total REE.

Evaluation of a Measurement System to Assess ICU Team Performance.

OBJECTIVE: Measuring teamwork is essential in critical care, but limited observational measurement systems exist for this environment. The objective of this study was to evaluate the reliability and validity of a behavioral marker system for measuring teamwork in ICUs. DESIGN: Instances of teamwork were observed by two raters for three tasks: multidisciplinary rounds, nurse-to-nurse handoffs, and retrospective videos of medical students and instructors performing simulated codes. Intraclass correlation coefficients were calculated to assess interrater reliability. Generalizability theory was applied to estimate systematic sources of variance for the three observed team tasks that were associated with instances of teamwork, rater effects, competency effects, and task effects. SETTING: A 15-bed surgical ICU at a large academic hospital. SUBJECTS: One hundred thirty-eight instances of teamwork were observed. Specifically, we observed 88 multidisciplinary rounds, 25 nurse-to-nurse handoffs, and 25 simulated code exercises. INTERVENTIONS: No intervention was conducted for this study. MEASUREMENTS AND MAIN RESULTS: Rater reliability for each overall task ranged from good to excellent correlation (intraclass correlation coefficient, 0.64-0.81), although there were seven cases where reliability was fair and one case where it was poor for specific competencies. Findings from generalizability studies provided evidence that the marker system dependably distinguished among teamwork competencies, providing evidence of construct validity. CONCLUSIONS: Teamwork in critical care is complex, thereby complicating the judgment of behaviors. The marker system exhibited great potential for differentiating competencies, but findings also revealed that more context specific guidance may be needed to improve rater reliability.

A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and application?

OBJECTIVE: Behavioural marker systems are advocated as a method for providing accurate assessments, directing feedback and determining the impact of teamwork improvement initiatives. The present article reports on the state of quality surrounding their use in healthcare and discusses the implications of these findings for future research, development and application. In doing so, this article provides a practical resource where marker systems can be selected and evaluated based on their strengths and limitations. METHODS: Four research questions framed this review: what are the attributes of behavioural marker systems? What evidence of reliability and validity exists? What skills and expertise are required for their use? How have they been applied to investigate the relationship between teamwork and other constructs? RESULTS: Behavioural markers systems are generally designed for specific work domains or tasks. They often cover similar content with inconsistent terminology, which complicates the comparison of research findings across clinical domains. Although several approaches were used to establish the reliability and validity of marker systems, the marker system literature, as a whole, requires more robust reliability and validity evidence. The impact of rater training on rater proficiency was mixed, but evidence suggests that improvements can be made over time. CONCLUSIONS: A consensus of definitions for teamwork constructs must be reached to ensure that the meaning behind behavioural measurement is understood across disciplines, work domains and task types. Future development efforts should focus on the cost effectiveness and feasibility of measurement tools including time spent training raters. Further, standards for the testing and reporting of psychometric evidence must be established. Last, a library of tools should be generated around whether the instrument measures general or domain-specific behaviours.

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

PURPOSE: Teamwork is essential for ensuring the quality and safety of health care delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research. METHODS: A keyword search of the PubMed database was conducted in February 2013. Keyword combinations focused on 3 areas: (1) teamwork, (2) the ICU, and (3) training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (ie, intradepartment) were selected for inclusion. RESULTS: Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies. CONCLUSIONS: Team research is burgeoning in the ICU, yet low-hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined, and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.