Rescue Improvement Conference: A Novel Tool for Addressing Failure to Rescue.

OBJECTIVE: To understand the effectiveness of Rescue Improvement Conference, a forum that addresses FTR. SUMMARY OF BACKGROUND DATA: Every year over 150,000 patients die after elective surgery in the United States. FTR is the phenomenon whereby delayed recognition and/or response to serious surgical complications leads to a progressive cascade of adverse events culminating in death. Rescue Improvement Conference is an adapted version of the Ottawa-style morbidity and mortality conference, designed to address common contributors to FTR: ineffective communication and inadequate problem solving. METHODS: Mixed methods data were used to evaluate Rescue Improvement Conference, a bi-monthly forum that was first introduced in our academic medical center in 2018. Conference effectiveness data were collected via survey and open-text responses after 5 conferences between September 2018 and February 2020. We focused on 5 indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and actionable opportunities for improvement. Twelve surgical faculty and house staff also provided feedback during semi-structured interviews. Qualitative data were analyzed using thematic analysis. RESULTS: Conference attendees (N = 140) felt that Rescue Improvement Conference was effective-all 5 indicators had mean scores above 5 on Likert scales. The qualitative data supports the quantitative findings, and 3 additional themes emerged: Rescue Improvement Conference enables the representation of diverse voices, promotes interdisciplinary collaboration, and encourages multilevel problem solving. CONCLUSIONS: Rescue Improvement Conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications by providing stakeholders a forum to identify and discuss factors that contribute to FTR.

Reducing Ileostomy Readmissions: Using Implementation Science to Evaluate the Adoption of a Quality Improvement Initiative.

BACKGROUND: Translating empirical evidence into clinical practice remains challenging. Prevention of morbidity from new ileostomies may serve as an example. Despite evidence demonstrating improvements in electrolyte levels, kidney function markers, and hospital readmissions, widespread adoption of oral rehydration solutions among patients with new ileostomies has not occurred. The causes of low uptake are unknown and likely multifactorial. OBJECTIVE: We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance implementation science framework to identify barriers and facilitators in the adoption of a quality improvement initiative aimed at decreasing emergency department visits and hospital readmissions because of dehydration among patients with new ileostomies using oral rehydration solutions. DESIGN: Qualitative interviews were conducted with stakeholders based on the domains of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. SETTINGS: Participating community and academic hospitals across Michigan (n = 12). PATIENTS: Convenience sampling was used to recruit 25 key stakeholders, including wound, ostomy, and continence nurses; registered nurses; nurse practitioners; nurse managers; colorectal surgeons; surgery residents; physician assistants; and data abstractors (1-4 participants per site). MAIN OUTCOME MEASURES: Through qualitative content analysis, we located, analyzed, and identified patterns using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. RESULTS: We identified the following factors to increase the adoption of quality improvement initiatives at the provider level: 1) selection and coaching of champions, 2) broadening of multidisciplinary teams, 3) performing structured patient follow-up, and 4) addressing long-term sustainability concerns regarding cost and equity. LIMITATIONS: Limited to high-volume ileostomy surgery hospitals, did not include in-person site visits to each hospital before and after implementation, and did not consider the hospital- and patient-level factors that impact the widespread adoption of quality improvement initiatives. CONCLUSIONS: Integrating implementation science frameworks to rigorously study quality improvement initiatives may reveal the determinants of the widespread adoption of evidence-based practices. REDUCCIN DE REINGRESOS POR ILEOSTOMA USO DE LA CIENCIA DE LA IMPLEMENTACIN PARA EVALUAR LA ADOPCIN DE UNA INICIATIVA DE MEJORA DE LA CALIDAD: ANTECEDENTES:Traducir la evidencia empírica a la práctica clínica sigue siendo un desafío. La prevención de la morbilidad por nuevas ileostomías puede servir como ejemplo. A pesar de la evidencia que demuestra mejoras en los niveles de electrolitos, marcadores de función renal y reingresos hospitalarios, no se ha producido una adopción generalizada de soluciones de rehidratación oral entre pacientes con nuevas ileostomías. Las causas de la baja captación son desconocidas y probablemente multifactoriales.OBJETIVO:Empleamos Alcance, Eficacia, Adopción, Implementación y Mantenimiento, un marco de las ciencias de implementación, para identificar barreras y facilitadores en la adopción de una iniciativa de mejora de la calidad destinada a disminuir las visitas al departamento de emergencias y los reingresos hospitalarios debido a la deshidratación entre los pacientes con nuevos ileostomías utilizando soluciones de rehidratación oral.DISEÑO:Se realizaron entrevistas cualitativas con las partes interesadas basadas en los dominios del marco de Alcance, Efectividad, Adopción, Implementación y Mantenimiento.CONFIGURACIÓN:Hospitales académicos y comunitarios participantes a través de Michigan (n = 12).PARTICIPANTES:Se utilizó un muestreo por conveniencia para reclutar a 25 partes interesadas clave, incluyendo enfermeras de heridas, ostomía y continencia; enfermeras registradas; enfermeras practicantes; gerentes de enfermera; cirujanos colorrectales; residentes de cirugía; asistentes médicos; y extractores de datos (1-4 participantes por sitio).PRINCIPALES MEDIDAS DE RESULTADO:A través del análisis de contenido cualitativo, localizamos, analizamos e identificamos patrones utilizando el marco de Alcance, Eficacia, Adopción, Implementación y Mantenimiento.RESULTADOS:Identificamos los siguientes factores para aumentar la adopción de iniciativas de mejora de la calidad a nivel de proveedores: 1) selección y entrenamiento de campeones, 2) ampliación de equipos multidisciplinarios, 3) seguimiento estructurado de pacientes y 4) abordaje a largo plazo. preocupaciones de sostenibilidad con respecto al costo y la equidad.LIMITACIONES:Limitado a hospitales de cirugía de ileostomía de alto volumen, incapaz de realizar visitas en persona a cada hospital antes y después de la implementación, no considera los factores a nivel del hospital y del paciente que afectan la adopción generalizada de iniciativas de mejora de la calidad.CONCLUSIONES:La integración de marcos científicos de implementación para estudiar rigurosamente las iniciativas de mejora de la calidad puede revelar los determinantes de la adopción generalizada de prácticas basadas en la evidencia. (Traducción-Dr. Aurian Garcia Gonzalez ).

Time-limited trials in the ICU: a mixed-methods sequential explanatory study of intensivists at two academic centres.

OBJECTIVE: To understand intensivist perceptions of the appropriateness of time-limited trials (TLTs)-a strategy to align life-sustaining care with patient goals and values in the midst of clinical uncertainty. DESIGN: We conducted a mixed-methods sequential explanatory study of intensive care unit (ICU) intensivists regarding appropriateness of utilising TLTs in three vignettes centred on invasive mechanical ventilation (IMV); continuous renal replacement therapy (CRRT); and heated high-flow nasal cannula (HHFNC). Semistructured interviews were conducted using the Tailored Implementation of Chronic Diseases framework. Data were analysed using thematic and matrix analysis. SETTING: Two academic medical centres in the USA participated in the randomised surveys and one centre participated in the semistructured interviews. PARTICIPANTS: Pulmonary and critical care intensivists and fellows. PRIMARY AND SECONDARY OUTCOMES: To understand intensivists perceptions of the appropriateness in using TLTs. RESULTS: Of 115 physicians surveyed, 71 initiated the survey and 44 completed the entire survey with a response rate of 38% (N=44/115) and a completion rate of 62% (N=44/71). While 35% (N=23/66) of intensivists had never heard of a TLT, of the intensivists who had heard of a TLT, 77% (N=33/43) had participated in one. In response to the vignettes, appropriateness of using a TLT varied (IMV: 74% (N=46/62); CRRT 78% (N=49/63); HHFNC 92% (N=56/61) as did the durations of the TLT. Semistructured interviews with 11 intensivists revealed having clarity about patient goals and clinical endpoints facilitated successful TLTs while lack of an evidenced-based framework was a barrier. CONCLUSION: More than half of the physicians who responded had conducted or participated in a TLT. To increase the use of TLTs in the ICU, clinicians desire a more robust, evidence-based framework on how to conduct TLTs.

Prioritizing evidence-based practices for acute respiratory distress syndrome using digital data: an iterative multi-stakeholder process.

BACKGROUND: Evidence-based practices (EBPs) for patients receiving invasive mechanical ventilation vary in the quality of their underlying evidence and ease of implementation. RESEARCH QUESTION: How do researchers and clinicians prioritize EBPs to help guide clinical decision-making and focus implementation efforts to improve patient care using existing, validated measures? STUDY DESIGN AND METHODS: We developed a 4-step rapid method using existing criteria to prioritize EBPs associated with lower mortality and/or shorter duration of invasive mechanical ventilation for patients suffering from acute respiratory failure or acute respiratory distress syndrome. Using different types of data including surveys, we (1) identified relevant EBPs, (2) rated EBPs using the Guideline Implementability Appraisal (GLIA) tool, (3) surveyed practicing ICU clinicians from different hospital systems using a subset of GLIA criteria, and (4) developed metrics to assess EBP performance. In this paper, we describe steps 2 and 3. RESULTS: In step 2, we prioritized 11 EBPs from an initial list of 30, using surveys and ratings among a small group of clinician researchers. In step 3, 42 clinicians from 8 different hospital systems provided assessments of these 11 EBPs which inform the final step of metric development. INTERPRETATION: Our prioritization process allowed us to identify 11 EBPs out of a larger group that clinicians perceive is most likely to help optimize invasive mechanical ventilation and improve the outcomes of this vulnerable patient population. While this method was developed in critical care related to adults receiving invasive mechanical ventilation, it is adaptable to other health contexts.

Psychological Safety in Intensive Care Unit Rounding Teams.

Rationale: Psychological safety is the condition by which members of an organization feel safe to voice concerns and take risks. Although psychological safety is an important determinant of team performance, little is known about its role in the intensive care unit (ICU). Objectives: To identify the factors associated with psychological safety and the potential influence of psychological safety on team performance in critical care. Methods: We performed daily surveys of healthcare providers in 12 ICUs within an integrated health system over a 2-week period. Survey domains included psychological safety, leader familiarity, leader inclusiveness, role clarity, job strain, and teamwork. These data were linked to daily performance on lung-protective ventilation and spontaneous breathing trials. We used regression models to examine the antecedents of psychological safety as well as the influence of psychological safety on both perceived teamwork and actual performance. Results: We received 553 responses from 270 unique providers. At the individual provider level, higher leader inclusiveness (adjusted ß = 0.32; 95% confidence interval [CI], 0.24 to 0.41) and lower job strain (adjusted ß = -0.07, 95% CI, -0.13 to -0.02) were independently associated with greater psychological safety. Higher psychological safety was independently associated with greater perception of teamwork (adjusted ß = 0.30; 95% CI, 0.25 to 0.36). There was no association between team psychological safety and performance on either spontaneous breathing trials (incident rate ratio for each 1-unit change in team psychological safety, 0.85; 95% CI, 0.81 to 1.10) or lung-protective ventilation (incident rate ratio, 0.77; 95% CI, 0.57 to 1.04). Conclusions: Psychological safety is associated with several modifiable factors in the ICU but is not associated with actual use of evidence-based practices.

An acceptability pilot of the facilitating active management in lung illness with engaged surrogates (FAMILIES) study.

Approximately half of the surrogate decision makers of critically ill adults are at risk for negative emotional burden. Decision support and effective surrogate-clinician communication buffers against such experiences. The objective of this study is to evaluate the acceptability of a new surrogate-targeted educational tool that promotes engagement with clinicians and advocacy for 2 evidence-based practices in the provision of mechanical ventilation for acute respiratory failure: spontaneous awakening and breathing trials.A panel of 44 former patients and surrogates of a 20-bed medical intensive care unit in a large academic hospital responded to an online survey. Acceptability was measured on 3 dimensions: attitudes toward the content and delivery of information, objective knowledge translation, and subjective knowledge acquisition.More than 80% of participants found the tool to be easy to read, and over 90% felt that the tool provided actionable recommendations. A significant number of previously unsure participants were able to identify what spontaneous awakening and breathing trials are and when they occur, and 16% to 36% reported significant improvements in their subjective understanding of the target evidence-based practices, after being exposed to the educational tool.This line of work seeks to reduce surrogates' negative emotional burden while also promoting quality critical care. The educational tool provides a promising new way to promote surrogate-clinician communication, by increasing surrogates' knowledge about and encouraging advocacy for evidence-based practices in the provision of mechanical ventilation.

"Reliable Sources" in Cable News: Analyzing Network Fragmentation in Coverage of Reform Policy.

News coverage of the Patient Protection and Affordable Care Act (PPACA) and President Obama's announced Clean Power Plan (CPP) served as data for two case studies. Social network analysis was used to investigate the sources used by cable giants CNN, Fox News, and MSNBC. Both case studies show the extent of sourcing varies across the three news outlets, with CNN using the smallest network, MSNBC using the largest, and Fox falling somewhere in between. Ultimately, the source networks of the three cable outlets were highly fragmented with the exception of high-profile politicians. While the number of sources used in PPACA coverage stayed relatively stable, sourcing of the CPP decreased over time. Results suggest different sourcing patterns and contextually driven agenda-building processes.

Evidence-Based Practices for Acute Respiratory Failure and Acute Respiratory Distress Syndrome: A Systematic Review of Reviews.

BACKGROUND: The recent pandemic highlights the essential nature of optimizing the use of invasive mechanical ventilation (IMV) in complex critical care settings. This review of reviews maps evidence-based practices (EBPs) that are associated with better outcomes among adult patients with acute respiratory failure or ARDS on the continuum of care, from intubation to liberation. RESEARCH QUESTION: What EPBs are recommended to reduce the duration of IMV and mortality rate among patients with acute respiratory failure/ARDS? STUDY DESIGN AND METHODS: We identified an initial set of reports that links EBPs to mortality rates and/or duration of IMV. We conducted a review of reviews, focusing on preappraised guidelines, meta-analyses, and systematic reviews. We searched Scopus, CINAHL, and PubMed from January 2016 to January 2019 for additional evidence that has not yet been incorporated into current guidelines. RESULTS: Our initial search produced 61 publications that contained 42 EBPs. We excluded 42 manuscripts during the data extraction process, primarily because they were not associated with improved patient outcomes. The remaining 19 preappraised guidelines, meta-analyses, and systematic reviews met our full inclusion criteria and spanned the continuum of IMV care from intubation to liberation. These contained 20 EBPs, a majority of which were supported with moderate levels of evidence. Of these, six EBPs focused on intubation and escalation of care, such as ventilator management and synchrony; ten EBPs reduced complications associated with IMV, which included spontaneous awakening and breathing trials and early mobility protocols; and four EBPs promoted timely extubation and postextubation recovery. INTERPRETATION: This review describes EBPs that are associated with fewer ventilator days and/or lower mortality rates among patients who received IMV for acute respiratory failure/ARDS. Many of these EBPs are connected across the care continuum, which indicates the need to promote and assess effective implementation jointly, rather than individually.

Communication expectations of critically ill patients and their families.

Little is known about specific expectations family members and other types of surrogates have regarding clinician interaction. The objective of this study is to describe communication expectations regarding clinician engagement when surrogates represent patients who are too critically ill to advocate on their own behalf. As part of a larger study, a panel of 44 former patients and surrogate decision makers of a 20-bed medical intensive care unit (ICU) housed within a large academic hospital in the Midwestern United States responded to an online survey. Findings suggest that participants held different expectations for different intensive care providers in that 98% expected to talk to an attending physician within 48 hours of their loved one being admitted to the ICU, while 88% expected to have spoken with a registered nurse, and 74% with a respiratory therapist. Only half expected to have talked with a resident or fellow, and a third to a social worker. Regarding communication frequency, 95% of participants expected to interact with the care team at least once a day, and 74% preferred for contact to be initiated by clinicians. Together this suggests that expectations for surrogate-clinician communication more closely aligned with current guidelines for family-centered care than they are with actual practice.

Teamwork in the intensive care unit.

Intensive care units (ICUs) provide care to the most severely ill hospitalized patients. Although ICUs increasingly rely on interprofessional teams to provide critical care, little about actual teamwork in this context is well understood. The ICU team is typically comprised of physicians or intensivists, clinical pharmacists, respiratory therapists, dieticians, bedside nurses, clinical psychologists, and clinicians-in-training. ICU teams are distinguished from other health care teams in that they are low in temporal stability, which can impede important team dynamics. Furthermore, ICU teams must work in physically and emotionally challenging environments. Our review of the literature reveals the importance of information sharing and decision-making processes, and identifies potential barriers to successful team performance, including the lack of effective conflict management and the presence of multiple and sometimes conflicting goals. Key knowledge gaps about ICU teams include the need for more actionable data linking ICU team structure to team functioning and patient-, family-, ICU-, and hospital-level outcomes. In particular, research is needed to better delineate and define the ICU team, identify additional psychosocial phenomena that impact ICU team performance, and address varying and often competing indicators of ICU team effectiveness as a multivariate and multilevel problem that requires better understanding of the independent effects and interdependencies between nested elements (i.e., hospitals, ICUs, and ICU teams). Ultimately, efforts to advance team-based care are essential for improving ICU performance, but more work is needed to develop actionable interventions that ensure that critically ill patients receive the best care possible. (PsycINFO Database Record