Sensor-based measurement of critical care nursing workload: Unobtrusive measures of nursing activity complement traditional task and patient level indicators of workload to predict perceived exertion.

OBJECTIVE: To establish the validity of sensor-based measures of work processes for predicting perceived mental and physical exertion of critical care nurses. MATERIALS AND METHODS: Repeated measures mixed-methods study in a surgical intensive care unit. Wearable and environmental sensors captured work process data. Nurses rated their mental (ME) and physical exertion (PE) for each four-hour block, and recorded patient and staffing-level workload factors. Shift was the grouping variable in multilevel modeling where sensor-based measures were used to predict nursing perceptions of exertion. RESULTS: There were 356 work hours from 89 four-hour shift segments across 35 bedside nursing shifts. In final models, sensor-based data accounted for 73% of between-shift, and 5% of within-shift variance in ME; and 55% of between-shift, and 55% of within-shift variance in PE. Significant predictors of ME were patient room noise (ß = 0.30, p < .01), the interaction between time spent and activity levels outside main work areas (ß = 2.24, p < .01), and the interaction between the number of patients on an insulin drip and the burstiness of speaking (ß = 0.19, p < .05). Significant predictors of PE were environmental service area noise (ß = 0.18, p < .05), and interactions between: entropy and burstiness of physical transitions (ß = 0.22, p < .01), time speaking outside main work areas and time at nursing stations (ß = 0.37, p < .001), service area noise and time walking in patient rooms (ß = -0.19, p < .05), and average patient load and nursing station speaking volume (ß = 0.30, p < .05). DISCUSSION: Analysis yielded highly predictive models of critical care nursing workload that generated insights into workflow and work design. Future work should focus on tighter connections to psychometric test development methods and expansion to a broader variety of settings and professional roles. CONCLUSIONS: Sensor-based measures are predictive of perceived exertion, and are viable complements to traditional task demand measures of workload.

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.

Developing a Comprehensive Model of Intensive Care Unit Processes: Concept of Operations.

OBJECTIVES: This study aimed to use a systems engineering approach to improve performance and stakeholder engagement in the intensive care unit to reduce several different patient harms. METHODS: We developed a conceptual framework or concept of operations (ConOps) to analyze different types of harm that included 4 steps as follows: risk assessment, appropriate therapies, monitoring and feedback, as well as patient and family communications. This framework used a transdisciplinary approach to inventory the tasks and work flows required to eliminate 7 common types of harm experienced by patients in the intensive care unit. The inventory gathered both implicit and explicit information about how the system works or should work and converted the information into a detailed specification that clinicians could understand and use. PROTOTYPE CONOPS TO ELIMINATE HARM: Using the ConOps document, we created highly detailed work flow models to reduce harm and offer an example of its application to deep venous thrombosis. In the deep venous thrombosis model, we identified tasks that were synergistic across different types of harm. We will use a system of systems approach to integrate the variety of subsystems and coordinate processes across multiple types of harm to reduce the duplication of tasks. Through this process, we expect to improve efficiency and demonstrate synergistic interactions that ultimately can be applied across the spectrum of potential patient harms and patient locations. CONCLUSIONS: Engineering health care to be highly reliable will first require an understanding of the processes and work flows that comprise patient care. The ConOps strategy provided a framework for building complex systems to reduce patient harm.

Towards expanding the acute care team: Learning how to involve families in care processes.

INTRODUCTION: Effective teamwork is known to be important to improving health care outcomes. Current research often highlights teamwork among health care professionals without consideration of approaches to including family as part of the health care team. In this study, the authors assess family and provider openness to expanding the care team to include family participation and introduce the Family Involvement Menu as a tool to facilitate family engagement. METHOD: They collected 37 family surveys and 37 clinician surveys to understand the perception, comfort level, experience, and interest of family and clinicians in including family in the care of the patient. The majority of family reported being interested and comfortable in participating in care (95% and 92%, respectively). RESULTS: The majority of clinicians considered family already to be part of the health care team (92%) though only 16% reported routinely inviting families to participate in direct patient care all the time. Multiple direct patient care activities were identified as promising opportunities for family engagement. Barriers to family engagement reported included the family being scared (19%), uncomfortable (19%), or unwilling (14%) or nurses not having enough time (14%) to involve families. DISCUSSION: Engaging family has the potential to increase nursing availability for other tasks, enhance relationship building, and is an opportunity to introduce early education for family, better preparing them for transition of care and discharge. The Family Involvement Menu supports family engagement and can be a strategy to include family members as part of the health care team.

A Collaborative Learning Network Approach to Improvement: The CUSP Learning Network.

BACKGROUND: Collaborative improvement networks draw on the science of collaborative organizational learning and communities of practice to facilitate peer-to-peer learning, coaching, and local adaption. Although significant improvements in patient safety and quality have been achieved through collaborative methods, insight regarding how collaborative networks are used by members is needed. Improvement Strategy: The Comprehensive Unit-based Safety Program (CUSP) Learning Network is a multi-institutional collaborative network that is designed to facilitate peer-to-peer learning and coaching specifically related to CUSP. Member organizations implement all or part of the CUSP methodology to improve organizational safety culture, patient safety, and care quality. Qualitative case studies developed by participating members examine the impact of network participation across three levels of analysis (unit, hospital, health system). In addition, results of a satisfaction survey designed to evaluate member experiences were collected to inform network development. RESULTS: Common themes across case studies suggest that members found value in collaborative learning and sharing strategies across organizational boundaries related to a specific improvement strategy. CONCLUSION: The CUSP Learning Network is an example of network-based collaborative learning in action. Although this learning network focuses on a particular improvement methodology-CUSP-there is clear potential for member-driven learning networks to grow around other methods or topic areas. Such collaborative learning networks may offer a way to develop an infrastructure for longer-term support of improvement efforts and to more quickly diffuse creative sustainment strategies.

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.

Nurse-perceived barriers to effective communication regarding prognosis and optimal end-of-life care for surgical ICU patients: a qualitative exploration.

BACKGROUND: Integration of palliative care for intensive care unit (ICU) patients is important but often challenging, especially in surgical ICUs (SICUs), in part because many surgeons equate palliative care with terminal care and failure of restorative care. SICU nurses, who are key front-line clinicians, can provide insights into barriers for delivery of optimal palliative care in their setting. METHODS: We developed a focus group guide to identify barriers to two key components of palliative care-optimal communication regarding prognosis and optimal end-of-life care-and used the tool to conduct focus groups of nurses providing bedside care in three SICUs at a tertiary care, academic, inner city hospital. Using content analysis technique, responses were organized into thematic domains that were validated by independent observers and a subset of participating nurses. RESULTS: Four focus groups included a total of 32 SICU nurses. They identified 34 barriers to optimal communication regarding prognosis, which were summarized into four domains: logistics, clinician discomfort with discussing prognosis, inadequate skill and training, and fear of conflict. For optimal end-of-life care, the groups identified 24 barriers in four domains: logistics, inability to acknowledge an end-of-life situation, inadequate skill and training, and cultural differences relating to end-of-life care. CONCLUSIONS: Nurses providing bedside care in SICUs identify barriers in several domains that may impede optimal discussions of prognoses and end-of-life care for patients with surgical critical illness. Consideration of these perceived barriers and the underlying SICU culture is relevant for designing interventions to improve palliative care in this setting.

Surgical intensive care unit clinician estimates of the adequacy of communication regarding patient prognosis.

INTRODUCTION: Intensive care unit (ICU) patients and family members repeatedly note accurate and timely communication from health care providers to be crucial to high-quality ICU care. Practice guidelines recommend improving communication. However, few data, particularly in surgical ICUs, exist on health care provider opinions regarding whether communication is effective. METHODS: To evaluate ICU clinician perceptions regarding adequacy of communication regarding prognosis, we developed a survey and administered it to a cross section of surgical ICU nurses, surgical ICU physicians, nurse practitioners (NPs), and surgeons. RESULTS: Surgeons had a high satisfaction with communication regarding prognosis for themselves (90%), ICU nurses (85%), and ICU physicians and NPs (85%). ICU nurses noted high satisfaction with personal (82%) and ICU physician and NP (71%) communication, but low (2%) satisfaction with that provided by surgeons. ICU physicians and NPs noted high satisfaction with personal (74%) and ICU nurse (88%) communication, but lower (23%) satisfaction with that provided by surgeons. ICU nurses were the most likely (75%) to report speaking to patients and patient families regarding prognosis, followed by surgeons (40%), and then ICU physicians and NPs (33%). Surgeons noted many opportunities to speak to ICU nurses and ICU physicians and NPs about patient prognosis and noted that comments were often valued. ICU physicians and NPs and ICU nurses noted many opportunities to speak to each other but fewer opportunities to communicate with surgeons. ICU physicians and NPs thought that their comments were valued by ICU nurses but less valued by surgeons. ICU nurses thought that their comments were less valued by ICU physicians and NPs and surgeons. CONCLUSIONS: ICU nurses, surgeons, and ICU intensivists and NPs varied widely in their satisfaction with communication relating to prognosis. Clinician groups also varied in whether they thought that they had opportunities to communicate prognosis and whether their concerns were valued by other provider groups. These results hint at the nuanced and complicated relationships present in surgical ICUs. Further validation studies and further evaluations of patient and family member perspectives are needed.

Medication reconciliation: developing and implementing a program.

During the past 5 years since the medication reconciliation process was formalized and automated, it has become an independent redundancy. The patient intervention rates are maintained at 30% to 35%, with ADE rates related to medication reconciliation at zero. The medication process takes into account the accuracy and appropriateness of restarting prehospital medications and current ICU medications. It includes the omission of important home medications along with inaccuracies of dosages and frequencies. This form assures that the patient is receiving continuity of care ad decreases complications of the patients health related to the changing of medications. Until recently this concept was disseminated by the staff without consistent administrative support. It was a process developed by nurses and perpetuated by nurses. Recently the administration has mandated that the process be implemented throughout the institution. A Hopkins health care-based collaborative is working to implement medication reconciliation hospital wide. The challenge exists in standardizing a process that is now specific to each functional unit. Multidisciplinary monthly meetings provided a forum for working through the barriers to incorporate these changes. This low-cost, high-impact safely initiative, if planned and performed strategically, can have a significant effect on patient safety.

Medication reconciliation: a practical tool to reduce the risk of medication errors.

Preventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.