Measurement properties and implementation of a checklist to assess leadership skills during interdisciplinary rounds in the intensive care unit.

The implementation of interdisciplinary teams in the intensive care unit (ICU) has focused attention on leadership behavior. A daily recurrent situation in ICUs in which both leadership behavior and interdisciplinary teamwork are integrated concerns the interdisciplinary rounds (IDRs). Although IDRs are recommended to provide optimal interdisciplinary and patient-centered care, there are no checklists available for leading physicians. We tested the measurement properties and implementation of a checklist to assess the quality of leadership skills in interdisciplinary rounds. The measurement properties of the checklist, which included 10 essential quality indicators, were tested for interrater reliability and internal consistency and by factor analysis. The interrater reliability among 3 raters was good (κ, 0.85) and the internal consistency was acceptable (α, 0.74). Factor analysis showed all factor loadings on 1 domain (>0.65). The checklist was further implemented during videotaped IDRs which were led by senior physicians and in which 99 patients were discussed. Implementation of the checklist showed a wide range of "no" and "yes" scores among the senior physicians. These results may underline the need for such a checklist to ensure tasks are synchronized within the team.

Quality improvement of interdisciplinary rounds by leadership training based on essential quality indicators of the Interdisciplinary Rounds Assessment Scale.

PURPOSE: The implementation of interdisciplinary teams in the intensive care unit (ICU) has focused attention on leadership behavior. Daily interdisciplinary rounds (IDRs) in ICUs integrate leadership behavior and interdisciplinary teamwork. The purpose of this intervention study was to measure the effect of leadership training on the quality of IDRs in the ICU. METHODS: A nonrandomized intervention study was conducted in four ICUs for adults. The intervention was a 1-day training session in a simulation environment and workplace-based feedback sessions. Measurement included 28 videotaped IDRs (total, 297 patient presentations) that were assessed with 10 essential quality indicators of the validated IDR Assessment Scale. Participants were 19 intensivists who previously had no formal training in leading IDRs. They were subdivided by cluster sampling into a control group (ten experienced intensivists) and intervention group (nine intensive care fellows). Mann-Whitney U test was used to compare results between control and intervention groups. RESULTS: Baseline measurements of control and intervention groups revealed two indicators that differed significantly. The frequency of yes ratings for the intervention group significantly increased for seven of the ten indicators from before to after intervention. The frequency of yes ratings after training was significantly greater in the intervention than control groups for eight of the ten essential quality indicators. CONCLUSIONS: The leadership training improved the quality of the IDRs performed in the ICUs. This may improve quality and safety of patient care.

Assessing the quality of interdisciplinary rounds in the intensive care unit.

PURPOSE: Interdisciplinary rounds (IDRs) in the intensive care unit (ICU) are increasingly recommended to support quality improvement, but uncertainty exists about assessing the quality of IDRs. We developed, tested, and applied an instrument to assess the quality of IDRs in ICUs. MATERIALS AND METHODS: Delphi rounds were done to analyze videotaped patient presentations and elaborated together with previous literature search. The IDR Assessment Scale was developed, statistically tested, and applied to 98 videotaped patient presentations during 22 IDRs in 3 ICUs for adults in 2 hospitals in Groningen, The Netherlands. RESULTS: The IDR Assessment Scale had 19 quality indicators, subdivided in 2 domains: "patient plan of care" and "process." Indicators were "essential" or "supportive." The interrater reliability of 9 videotaped patient presentations among at least 3 raters was satisfactory (κ = 0.85). The overall item score correlations between 3 raters were excellent (r = 0.80-0.94). Internal consistency in 98 videotaped patient presentations was acceptable (α = .78). Application to IDRs demonstrated that indicators could be unambiguously rated. CONCLUSIONS: The quality of IDRs in the ICU can be reliably assessed for patient plan of care and process with the IDR Assessment Scale.

Variations in hospital worker perceptions of safety culture.

OBJECTIVE: To compare the attitudes toward and perceptions of institutional practices that can influence patient safety between all professional groups at a university medical center. DESIGN: A questionnaire measuring nine dimensions of organizational and safety culture was distributed to all hospital workers. Each item was rated on a 1 ('strongly disagree') to 5 ('strongly agree') scale. PARTICIPANTS: Professionals (2995), grouped as 'physicians' (16.6%), 'nurses' (40.3%), 'clinical workers' (e.g. psychologists; 21.7%), 'laboratory workers' (e.g. technicians; 11%) and 'non-medical workers' (e.g. managers; 10.4%). MAIN OUTCOME MEASURES: One-way analysis of variances (ANOVAs) carried out separately on each dimension with professional group as the independent variable of interest. RESULTS: Differences in ratings of organizational and safety culture were found across professional groups. Physicians and non-medical workers tended to rate the dimensions of organizational and safety culture more positively than did nurses, clinical workers and laboratory workers. For example, physicians gave more positive ratings of 'institutional commitment to safety' than did nurses, clinical workers and laboratory workers (mean = 3.71 vs. 3.62, 3.61 and 3.58, respectively, P < 0.01) and non-medical workers gave more positive ratings than did physicians, nurses, clinical workers and laboratory workers to 'perceptions towards the hospital' (mean = 3.69 vs. 3.39, 3.36, 3.49 and 3.47, respectively, P < 0.001). CONCLUSIONS: Interventions to promote safety culture should be tailored to the target group as attitudes and perceptions may differ among groups.

Demographic differences between health care workers who did or did not respond to a safety and organizational culture survey.

BACKGROUND: Areas for institutional improvement to enhance patient safety are commonly identified by surveying health care workers' (HCWs) attitudes, values, beliefs, perceptions and assumptions regarding institutional practices. An ideal response rate of 100% is rarely achieved in such surveys, and non-response bias can occur when non-respondents differ from respondents on a dimension likely to influence survey conclusions. The conditions for non-response bias to occur can be detected by comparing demographic characteristics of respondents and non-respondents and relating any differences to findings in the literature of differences in the construct of interest as a function of these demographic characteristics. The current study takes this approach. FINDINGS: All 5,609 HCWs at a university medical center were invited to participate in a survey measuring safety and organizational culture (response rate = 53.40%). Respondents indicated their professional group, gender, age group, years of working in the hospital and executive function. Because all HCWs were invited, the demographic composition of the group who did not respond was known. Differences in the demographic composition of respondents and non-respondents were compared using separate Pearson's chi-square tests for each demographic characteristic.Nurses and clinical workers were generally more likely to respond than were physicians, laboratory workers and non-medical workers. Male HCWs were less likely to respond than were females, HCWs aged younger than 45 years old had a lower response rate than did HCWs aged 45 to 54 years old, HCWs who had worked in the hospital for less than 5 years were less likely to respond than were those who had worked in the hospital for 5 years or more and HCWs without an executive function were less likely to respond than were executives. CONCLUSIONS: Demographic characteristics can be linked to response rates and need to be considered in conducting surveys among HCWs. The possibility of non-response bias can be reduced by conducting analyses separately as a function of relevant demographic characteristics, sampling a higher percentage of groups that are known to be less likely to respond, or weighting responses with the reciprocal of the response rate for the respective demographic group.

Perceptions of personal health risks by medical and non-medical workers in a university medical center: a survey study.

BACKGROUND: Health care workers (HCWs) are faced with many work-related choices which may depend on how they perceive risk, such as whether or not to comply with safety regulations. Little research has investigated risk perception in medical workers in comparison with non-medical workers and the extent to which risk perception differs in these groups. The current study thus investigates risk perception of medical and non-medical workers to inform and complement future research on safety compliance. The study has implications for the design of intervention programmes to increase the level of compliance of HCWs. METHODS: A survey study was conducted in which questionnaires were distributed to 6380 HCWs. The questionnaire asked for ratings of risk perception for cold, annual influenza, pandemic influenza, cancer, heart attack and food poisoning. Of 2495 returned questionnaires (response rate: 39%), 61.40% were from medical workers (24.1% of these were from physicians, 39.7% from nurses and 36.2% from paramedics) and 38.60% were from non-medical workers. RESULTS: Medical workers gave lower risk perception ratings than did non-medical workers for cancer, but not for other health risks. Within the medical workers, physicians rated the risk of getting a cold as higher, but of having a heart attack as lower than did nurses and paramedics; physicians also rated their risk of getting cancer as lower than did nurses. Perceived risk was higher as a function of age for pandemic influenza, cancer and heart attack, but lower for cold and annual influenza. HCWs who lived with a partner and children rated the risk of getting a cold or annual influenza higher than those who lived alone or with a partner only. Full-time HCWs gave lower ratings for annual influenza than did part-time HCWs. CONCLUSIONS: Different base levels of risk perception between medical and non-medical workers need to be taken into account for successful implementation of safety regulations.Intervention programmes to improve compliance with safety regulations may need to be customized for different groups as a function of how they perceive risk.

Efficacy beliefs predict collaborative practice among intensive care unit nurses.

AIM: This paper is a report of an investigation of whether intensive care nurses' efficacy beliefs predict future collaborative practice, and to test the potential mediating role of team commitment in this relationship. BACKGROUND: Recent empirical studies in the field of work and organizational psychology have demonstrated that (professional) efficacy beliefs are reciprocally related to workers' resources and well-being over time, resulting in a positive gain spiral. Moreover, there is ample evidence that workers' affective commitment to their organization or work-team is related to desirable work behaviours such as citizenship behaviour. METHODS: A longitudinal design was applied to questionnaire data from the EURICUS-project. Structural Equation Modelling was used to analyse the data. The sample consisted of 372 nurses working in 29 different European intensive care units. Data were collected in 1997 and 1998. However, our research model deals with fundamental psychosocial processes that are not time-dependent. Moreover, recent empirical literature shows that there is still room for improvement in ICU collaborative practice. RESULTS: The hypotheses that (i) the relationship between efficacy beliefs and collaborative practice is mediated by team commitment and (ii) efficacy beliefs, team commitment and collaborative practice are reciprocally related were supported, suggesting a potential positive gain spiral of efficacy beliefs. CONCLUSION: Healthcare organizations should create working environments that provide intensive care unit nurses with sufficient resources to perform their job well. Further research is needed to design and evaluate interventions for the enhancement of collaborative practice in intensive care units.

Pandemic influenza and pediatric intensive care.

OBJECTIVE: To assess the adequacy of preparedness planning for an influenza pandemic by modeling the pediatric surge capacity of healthcare facility and pediatric intensive care unit (PICU) requirements over time. Governments and Public Health authorities have planned preparedness activities and training for a flu pandemic. PICU facilities will be the limiting factor in healthcare provision for children but detailed analyses for needs and demands in PICU care have not been published. DESIGN: Based on the Center for Disease Control and Prevention and World Health Organization estimates and published models of the expected evolution of pandemic flu, we modeled the pediatric surge capacity of healthcare facility and PICU requirements over time. Various scenarios with different assumptions were explored. We compared these demands with estimates of maximal PICU capacity factoring in healthcare worker absenteeism as well as reported and more realistic estimates derived from semistructured telephone interviews with key stakeholders in ICUs in the study area. SETTING: All hospitals and intensive care facilities in the Northern Region in The Netherlands with near 1.7 million inhabitants, of whom approximately 25% is <18 yrs. MEASUREMENTS AND MAIN RESULTS: Using well-established modeling techniques, evidence-based medicine, and incorporating estimates from the Centers for Disease Control and Prevention and World Health Organization, we show that PICU capacity may suffice during an influenza pandemic. Even during the peak of the pandemic, most children requiring PICU admission may be served, even those who have nonflu-related conditions, provided that robust indications and decision rules are maintained, both for admission, as well as continuation (or discontinuation) of life support. CONCLUSIONS: We recommend that a model, with assumptions that can be adapted with new information obtained during early stages of the pandemic that is evolving, be an integral part of a preparedness plan for a pandemic influenza with new human transmissible agent like influenza A virus.

Pandemic influenza and excess intensive-care workload.

In The Netherlands a major part of preparedness planning for an epidemic or pandemic consists of maintaining essential public services, e.g., by the police, fire departments, army personnel, and healthcare workers. We provide estimates for peak demand for healthcare workers, factoring in healthcare worker absenteeism and using estimates from published epidemiologic models on the expected evolution of pandemic influenza in relation to the impact on peak surge capacity of healthcare facilities and intensive care units (ICUs). Using various published scenarios, we estimate their effect in increasing the availability of healthcare workers for duty during a pandemic. We show that even during the peak of the pandemic, all patients requiring hospital and ICU admission can be served, including those who have non-influenza-related conditions. For this rigorous task differentiation, clear hierarchical management, unambiguous communication, and discipline are essential and we recommend informing and training non-ICU healthcare workers for duties in the ICU.

Pandemic influenza and hospital resources.

Using estimates from the Centers for Disease Control and Prevention, the World Health Organization, and published models of the expected evolution of pandemic influenza, we modeled the surge capacity of healthcare facility and intensive care unit (ICU) requirements over time in northern Netherlands (approximately 1.7 million population). We compared the demands of various scenarios with estimates of maximum ICU capacity, factoring in healthcare worker absenteeism as well as reported and realistic estimates derived from semistructured telephone interviews with key management in ICUs in the study area. We show that even during the peak of the pandemic, most patients requiring ICU admission may be served, even those who have non-influenza-related conditions, provided that strong indications and decision-making rules are maintained for admission as well as for continuation (or discontinuation) of life support. Such a model should be integral to a preparedness plan for a pandemic with a new human-transmissible agent.

Predictive effect of p53 and p21 alteration on chemotherapy response and survival in locally advanced adenocarcinoma of the esophagus.

BACKGROUND: Cell cycle regulating proteins (p53/p21) and proliferation index Ki-67 have been associated with prognosis and response to chemotherapy. The aim of this study was to determine the significance of these molecular markers on tumor response and prognostic effect in a group of esophageal cancer patients treated with neoadjuvant chemotherapy. PATIENTS AND METHODS: Immunohistochemical expression of p53/p21 and Ki-67 was examined in pre-treatment biopsy specimen of 30 patients, in phase II neoadjuvant studies for locally advanced adenocarcinoma of the esophagus, who underwent surgery. Seven patients (23%) had progressive disease. Resection was achieved in all responders (n=23; 77%) and histochemical expression of the above-mentioned proliferating markers was examined in pre-treatment and resection specimens after chemotherapy. RESULTS: Responders had a significantly better survival compared to non-responders (p=0.001). Expression of p53, p21 and high Ki-67 in pre-treatment specimens was 73% (22/30), 63% (19/30) and 30% (10/30), respectively and was not related to response to chemotherapy. However, alteration in expression of p53-positivity in the pre-treatment specimens to p53-negativity in the resection specimens and p21-negativity to p21-positivity in 6 of the 23 (26%) resected tumors was correlated with better response and survival (p=0.011). CONCLUSION: Data from this study showed that alteration of p53 and p21 expression rather than the initial expression seems to be related to chemotherapy response and overall survival in patients with esophageal adenocarcinoma.

Pregnancy and early-stage melanoma.

BACKGROUND: Cutaneous melanomas are aggressive tumors with an unpredictable biologic behavior. It has been suggested that women who present with melanoma during pregnancy have a worse prognosis due to more aggressive behavior of the melanoma. The objective of the current study was to evaluate the long-term effect of pregnancy on disease progression in women with Stage I-II melanoma. METHODS: From 1965 to 2001, 46 pregnant women were treated for a Stage I-II melanoma at the University Medical Center Groningen. These patients were compared with an age-matched and gender-matched control group (nonpregnant) of 368 women with Stage I-II melanoma. The patients were staged according to the 2002 American Joint Committee on Cancer TNM classification system for melanoma. The 10-year disease-free survival (DFS) and 10-year overall survival (OS) rates were calculated using logistic regression analysis. RESULTS: The median age of patients in the pregnant group was 30 years (range, 18-46 years), and the median age of patients in the nonpregnant group was 36 years (range, 17-45 years). The median follow-up was 109 months (range, 1-356 months). Pregnant patients presented more often with thicker melanomas (median, 2.0 mm vs. 1.7 mm; not statistically significant). No differences with regard to tumor location, histologic subtype, tumor ulceration, or vascular invasion were detected between the pregnant group and the nonpregnant group. There was no statistical difference in the 10-year DFS and 10-year OS rates between the two groups. The 10-year DFS rates for patients in the pregnant and nonpregnant groups, respectively, were 88% versus 86% for patients with Stage I melanoma and 67% versus 73% for patients with Stage II melanoma. The 10-year OS rates for patients in the pregnant and nonpregnant groups, respectively, were 94% versus 90% for patients with Stage I melanoma and 82% versus 81% for patients with Stage II melanoma. CONCLUSIONS: Pregnancy does not appear to have an adverse, long-term effect on survival in patients with clinically localized melanoma. Further studies should address whether pregnant patients present with thicker lesions and/or whether they have decreased DFS compared with nonpregnant women. The prognosis for women with melanoma during pregnancy, as it relates to survival, still is dependent on tumor thickness and ulceration.

Expression of estrogen receptor, progesterone receptor, and insulin-like growth factor receptor-1 and of MIB-1 in patients with recurrent pleomorphic adenoma of the parotid gland.

BACKGROUND: Patients with recurrent pleomorphic adenomas of the parotid gland are difficult to manage without considerable risk of facial nerve injury. The prognostic significance of progesterone receptor (PR) and estrogen receptor (ER) reported in these adenomas was evaluated in patients with recurrent pleomorphic adenomas, comparing the results in a group of patients with primary adenomas without recurrences during 10 years of follow-up. METHODS: Paraffin embedded tumor samples from 52 patients with recurrent pleomorphic adenoma of the parotid gland were collected and stained immunohistochemically. Expression of PR, ER, Ki-67 antigen, and insulin-like growth factor receptor-1 (IGFR-1) was analyzed in resected samples of recurrent tumors and was compared with samples from a control group of patients with primary pleomorphic adenoma. RESULTS: A difference (P < 0.05) in the type of tumor was observed between the recurrent group (more cell-poor variants) and the control group. ER expression was low in both groups (19% and 17%, respectively), but immunoreactivity for ER was higher (48%) in normal parotid gland tissue. PR expression in the recurrent group (96%) was higher compared with PR expression in the control group (61%; P < 0.001). PR expression and IGFR-1 expression were correlated weakly (correlation coefficient = 0.660; P = 0.053) in the recurrent group. The expression of growth fraction (Ki-67 score) and IGFR-1 was similar in both groups but was more extensive compared with normal parotid gland tissue. CONCLUSIONS: PR seems to be a prognostic factor in recurrent pleomorphic adenoma of the parotid gland. The PR pathway can be considered a potential target for hormone treatment in patients with these recurrent adenomas.