Quantitative studies have demonstrated several factors predictive of readmissions to intensive ca... more Quantitative studies have demonstrated several factors predictive of readmissions to intensive care. Clinical decision tools, derived from these factors have failed to reduce readmission rates. The purpose of this study was to qualitatively explore the experiences and perceptions of physicians and nurses to gain more insight into intensive care readmissions. Semi-structured interviews of intensive care unit (ICU) and general medicine care providers explored work routines, understanding and perceptions of the discharge process, and readmissions to intensive care. Participants included ten providers from the ICU setting, including nurses (n = 5), consultant intensivists (n = 2), critical care fellows (n = 3) and 9 providers from the general medical setting, nurses (n = 4), consulting physicians (n = 2) and senior resident physicians (n = 3). Principles of grounded theory were used to analyze the interview transcripts. Nine factors within four broad themes were identified: (1) patient ...
Journal of clinical monitoring and computing, Jan 18, 2016
Increasing process complexity in the pediatric intensive care unit (PICU) can lead to information... more Increasing process complexity in the pediatric intensive care unit (PICU) can lead to information overload resulting in missing pertinent information and potential errors during morning rounds. An efficient model using a novel electronic rounding tool was designed as part of a broader critical care decision support system-checklist for early recognition and treatment of acute illness and injury in pediatrics (CERTAINp). We aimed to evaluate its impact on improving the process of care during rounding. Prospective pre- and post-interventional data included: team performance baseline assessment, patient safety discussion, guideline adherence, rounding time, and a survey of Residents' and Nurses' perception using a Likert scale. Attending physicians were blinded to the components of the assessment. A total of 113 pre-intervention and 114 post-intervention roundings were recorded by direct observation. Pre-intervention (108) and post-intervention staff surveys (80) were obtained....
Annals of the American Thoracic Society, Jan 2, 2016
Respiratory failure represents a major risk for morbidity and mortality. While generally managed ... more Respiratory failure represents a major risk for morbidity and mortality. While generally managed in the intensive care unit (ICU), respiratory failure often begins elsewhere. Checklists of care processes to minimize the duration of mechanical ventilation and adverse events are routinely used in the ICU, but are uncommonly used outside the ICU. To develop consensus among a multidisciplinary expert panel on care practices to include in a checklist of best practices for critically ill patients with respiratory failure before and after ICU admission. A multidisciplinary expert panel was assembled. The panel was tasked with creating a checklist of care processes aimed at decreasing progression to respiratory failure, duration of mechanical ventilation, mortality in mechanical ventilation and adverse events. Over the course of multiple teleconferences and email communications, the PRevention of Organ Failure Checklist (PROOFCheck) list was reviewed, refined and voted upon. Items that rece...
World journal of critical care medicine, Jan 4, 2015
Processes to ensure world-wide best-practice for critical care delivery are likely to minimize pr... more Processes to ensure world-wide best-practice for critical care delivery are likely to minimize preventable death, disability and costly complications for any healthcare system's sickest patients, but no large-scale efforts have so far been undertaken towards these goals. The advances in medical informatics and human factors engineering have provided possibility for novel and user-friendly clinical decision support tools that can be applied in a complex and busy hospital setting. To facilitate timely and accurate best-practice delivery in critically ill patients international group of intensive care unit (ICU) physicians and researchers developed a simple decision support tool: Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN). The tool has been refined and tested in high fidelity simulated clinical environment and has been shown to improve performance of clinical providers faced with simulated emergencies. The aim of this international educational interven...
The new Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards for resi... more The new Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards for residents and fellows went into effect in 2011. These regulations were designed to reduce fatigue-related medical errors and improve patient safety. The new shift restrictions, however, have led to more frequent transitions in patient care (handoffs), resulting in greater opportunity for communication breakdowns between caregivers, which correlate with medical errors and adverse events. Recent research has focused on improving the quality of these transitions through standardization of the handoff protocols; however, no attention has been given to reducing the number of transitions in patient care. This research leverages integer programming methods to design a work shift schedule for trainees that minimizes patient handoffs while complying with all ACGME duty-hour standards, providing required coverage, and maintaining physician quality of life. In a case study of redesigning the trainees' schedule for a Mayo Clinic Medical Intensive Care Unit (MICU), we show that the number of patient handoffs can be reduced by 23 % and still meet all required and most desired scheduling constraints. Furthermore, a 48 % reduction in handoffs could be achieved if only the minimum required rules are satisfied.
Efficient and effective functioning of intensive care units (ICU) has a significant impact on the... more Efficient and effective functioning of intensive care units (ICU) has a significant impact on the safety of patients who are critically sick, performance of care providers, utilization of clinical resources, and is essential for improving the overall healthcare delivery. This study focuses on developing a better understanding of ICU rounding process, which is a team-based activity and is routinely conducted with the objective of providing an error-free and customized treatment plan for each patient admitted to an ICU. However, rounding process is complex, ill-understood and marred by numerous inefficiencies. In this study, we develop process framework for ICU care delivery that integrates various pathophysiologic, care delivery and intervention processes. We do this by examining the rounding workflow of two major teaching hospitals in the US. One major issue for rounding process is interruptions. We suggest and test strategies for improving ICU rounding workflow by managing interruptions. This is accomplished through the development of simulation models to compare the relative merits of controlling interruptions in ICU with respect to overall rounding completion time. We found that as much as 39% time savings can be realized with alternate interruption control methods.
PURPOSE: Morning rounds in the intensive care unit (ICU) enables multidisciplinary providers to i... more PURPOSE: Morning rounds in the intensive care unit (ICU) enables multidisciplinary providers to interact and exchange information regarding patient care. ICU rounds are characterized by unique challenges including high acuity illness, frequent interruptions and processing of large quantities of highly dynamic data. These intersecting features complicate attempts to reliably characterize the structure and function of ICU rounds. Most existing studies have surveyed rounds participants, typically outside of the ICU setting. The aim of this study is to develop and validate a rounding observational tool that could be deployed in a working ICU environment by medically trained observers. METHODS: Investigators designed a survey inquiring about ICU rounding practice and distributed it to all members of the multidisciplinary rounding team in a tertiary teaching hospital. Seventy five surveys were collected for a response rate of 71.4%. Answers were grouped thematically and used as a reference to define 13 discrete rounding tasks in three defined locations (bedside, outside room, remote). Specific definitions and standard of operation for each task were vetted by an expert group and integrated into a web-based tool with multiple timer/event interfaces. After initial training sessions the final version of the tool was calibrated and interobserver variability was calculated. RESULTS: Over a two month period two independent, trained observers performed 16 paired observations of individual providers during 27 hours of ICU rounds. Interobserver variability was assessed showing good to excellent task categorizations (Kappa 0.87). Associated Bland-Altman plots showed consistent agreement of major provider's specific task duration, such as presentation (p=0.48, mean difference-0.02), discussion (p=0.21, mean difference-0.99), data gathering (p= 0.15, mean difference-0.39) CONCLUSIONS: This novel observation tool for ICU rounds provides a reliable method to record real time performance of common ICU rounding tasks by multidisciplinary providers. CLINICAL IMPLICATIONS: The observation tool will be used to observe rounding practice in various ICUs in order to characterize the process and to develop strategies and interventions to improve the efficiency of ICU rounds.
Adverse events and medical errors (AEs/MEs) are more likely to occur in the intensive care unit (... more Adverse events and medical errors (AEs/MEs) are more likely to occur in the intensive care unit (ICU). Information about the incidence and outcomes of such events is conflicting. A systematic review and meta-analysis were conducted to examine the effects of MEs/AEs on mortality and hospital and ICU lengths of stay among ICU patients. Potentially eligible studies were identified from 4 major databases. Of 902 studies screened, 12 met the inclusion criteria, 10 of which are included in the quantitative analysis. Patients with 1 or more MEs/AEs (vs no MEs/AEs) had a nonsignificant increase in mortality (odds ratio = 1.5; 95% confidence interval [CI] = 0.98-2.14) but significantly longer hospital and ICU stays; the mean difference (95% CI) was 8.9 (3.3-14.7) days for hospital stay and 6.8 (0.2-13.4) days for ICU. The ICU environment is associated with a substantial incidence of MEs/AEs, and patients with MEs/AEs have worse outcomes than those with no MEs/AEs.
Critical care delivery is a complex, expensive, error prone, medical specialty and remains the fo... more Critical care delivery is a complex, expensive, error prone, medical specialty and remains the focal point of major improvement efforts in healthcare delivery. Various modeling and simulation techniques offer unique opportunities to better understand the interactions between clinical physiology and care delivery. The novel insights gained from the systems perspective can then be used to develop and test new treatment strategies and make critical care delivery more efficient and effective. However, modeling and simulation applications in critical care remain underutilized. This article provides an overview of major computer-based simulation techniques as applied to critical care medicine. We provide three application examples of different simulation techniques, including a) pathophysiological model of acute lung injury, b) process modeling of critical care delivery, and c) an agent-based model to study interaction between pathophysiology and healthcare delivery. Finally, we identify ...
Although tranexamic acid is used to reduce bleeding after cardiac surgery, there is large variati... more Although tranexamic acid is used to reduce bleeding after cardiac surgery, there is large variation in the recommended dose, and few studies of plasma concentrations of the drug during cardiopulmonary bypass (CPB) have been performed. The plasma tranexamic acid concentration reported to inhibit fibrinolysis in vitro is 10 microg/mL. Twenty-one patients received an initial dose of 10 mg/kg given over 20 min followed by an infusion of 1 mg. kg(-1). h(-1) via a central venous catheter. Two patients were removed from the study secondary to protocol violation. Perioperative plasma tranexamic acid concentrations were measured with high-performance liquid chromatography. Plasma tranexamic acid concentrations (microg/mL; mean +/- SD [95% confidence interval]) were 37.4 +/- 16.9 (45.5, 29.3) after bolus, 27.6 +/- 7.9 (31.4, 23.8) after 5 min on CPB, 31.4 +/- 12.1 (37.2, 25.6) after 30 min on CPB, 29.2 +/- 9.0 (34.6, 23.8) after 60 min on CPB, 25.6 +/- 18.6 (35.1, 16.1) at discontinuation of tranexamic acid infusion, and 17.7 +/- 13.1 (24.1, 11.1) 1 h after discontinuation of tranexamic acid infusion. Four patients with renal insufficiency had increased concentrations of tranexamic acid at discontinuation of the drug. Repeated-measures analysis revealed a significant main effect of abnormal creatinine concentration (P = 0.02) and time (P < 0.001) on plasma tranexamic acid concentration and a significant time x creatinine concentration interaction (P < 0.001). A 10 mg/kg initial dose of tranexamic acid followed by an infusion of 1 mg.kg(-1).h(-1)produced plasma concentrations throughout the cardiopulmonary bypass period sufficient to inhibit fibrinolysis in vitro. The dosing of tranexamic acid may require adjustment for renal insufficiency.
Quantitative studies have demonstrated several factors predictive of readmissions to intensive ca... more Quantitative studies have demonstrated several factors predictive of readmissions to intensive care. Clinical decision tools, derived from these factors have failed to reduce readmission rates. The purpose of this study was to qualitatively explore the experiences and perceptions of physicians and nurses to gain more insight into intensive care readmissions. Semi-structured interviews of intensive care unit (ICU) and general medicine care providers explored work routines, understanding and perceptions of the discharge process, and readmissions to intensive care. Participants included ten providers from the ICU setting, including nurses (n = 5), consultant intensivists (n = 2), critical care fellows (n = 3) and 9 providers from the general medical setting, nurses (n = 4), consulting physicians (n = 2) and senior resident physicians (n = 3). Principles of grounded theory were used to analyze the interview transcripts. Nine factors within four broad themes were identified: (1) patient ...
Journal of clinical monitoring and computing, Jan 18, 2016
Increasing process complexity in the pediatric intensive care unit (PICU) can lead to information... more Increasing process complexity in the pediatric intensive care unit (PICU) can lead to information overload resulting in missing pertinent information and potential errors during morning rounds. An efficient model using a novel electronic rounding tool was designed as part of a broader critical care decision support system-checklist for early recognition and treatment of acute illness and injury in pediatrics (CERTAINp). We aimed to evaluate its impact on improving the process of care during rounding. Prospective pre- and post-interventional data included: team performance baseline assessment, patient safety discussion, guideline adherence, rounding time, and a survey of Residents' and Nurses' perception using a Likert scale. Attending physicians were blinded to the components of the assessment. A total of 113 pre-intervention and 114 post-intervention roundings were recorded by direct observation. Pre-intervention (108) and post-intervention staff surveys (80) were obtained....
Annals of the American Thoracic Society, Jan 2, 2016
Respiratory failure represents a major risk for morbidity and mortality. While generally managed ... more Respiratory failure represents a major risk for morbidity and mortality. While generally managed in the intensive care unit (ICU), respiratory failure often begins elsewhere. Checklists of care processes to minimize the duration of mechanical ventilation and adverse events are routinely used in the ICU, but are uncommonly used outside the ICU. To develop consensus among a multidisciplinary expert panel on care practices to include in a checklist of best practices for critically ill patients with respiratory failure before and after ICU admission. A multidisciplinary expert panel was assembled. The panel was tasked with creating a checklist of care processes aimed at decreasing progression to respiratory failure, duration of mechanical ventilation, mortality in mechanical ventilation and adverse events. Over the course of multiple teleconferences and email communications, the PRevention of Organ Failure Checklist (PROOFCheck) list was reviewed, refined and voted upon. Items that rece...
World journal of critical care medicine, Jan 4, 2015
Processes to ensure world-wide best-practice for critical care delivery are likely to minimize pr... more Processes to ensure world-wide best-practice for critical care delivery are likely to minimize preventable death, disability and costly complications for any healthcare system's sickest patients, but no large-scale efforts have so far been undertaken towards these goals. The advances in medical informatics and human factors engineering have provided possibility for novel and user-friendly clinical decision support tools that can be applied in a complex and busy hospital setting. To facilitate timely and accurate best-practice delivery in critically ill patients international group of intensive care unit (ICU) physicians and researchers developed a simple decision support tool: Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN). The tool has been refined and tested in high fidelity simulated clinical environment and has been shown to improve performance of clinical providers faced with simulated emergencies. The aim of this international educational interven...
The new Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards for resi... more The new Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards for residents and fellows went into effect in 2011. These regulations were designed to reduce fatigue-related medical errors and improve patient safety. The new shift restrictions, however, have led to more frequent transitions in patient care (handoffs), resulting in greater opportunity for communication breakdowns between caregivers, which correlate with medical errors and adverse events. Recent research has focused on improving the quality of these transitions through standardization of the handoff protocols; however, no attention has been given to reducing the number of transitions in patient care. This research leverages integer programming methods to design a work shift schedule for trainees that minimizes patient handoffs while complying with all ACGME duty-hour standards, providing required coverage, and maintaining physician quality of life. In a case study of redesigning the trainees' schedule for a Mayo Clinic Medical Intensive Care Unit (MICU), we show that the number of patient handoffs can be reduced by 23 % and still meet all required and most desired scheduling constraints. Furthermore, a 48 % reduction in handoffs could be achieved if only the minimum required rules are satisfied.
Efficient and effective functioning of intensive care units (ICU) has a significant impact on the... more Efficient and effective functioning of intensive care units (ICU) has a significant impact on the safety of patients who are critically sick, performance of care providers, utilization of clinical resources, and is essential for improving the overall healthcare delivery. This study focuses on developing a better understanding of ICU rounding process, which is a team-based activity and is routinely conducted with the objective of providing an error-free and customized treatment plan for each patient admitted to an ICU. However, rounding process is complex, ill-understood and marred by numerous inefficiencies. In this study, we develop process framework for ICU care delivery that integrates various pathophysiologic, care delivery and intervention processes. We do this by examining the rounding workflow of two major teaching hospitals in the US. One major issue for rounding process is interruptions. We suggest and test strategies for improving ICU rounding workflow by managing interruptions. This is accomplished through the development of simulation models to compare the relative merits of controlling interruptions in ICU with respect to overall rounding completion time. We found that as much as 39% time savings can be realized with alternate interruption control methods.
PURPOSE: Morning rounds in the intensive care unit (ICU) enables multidisciplinary providers to i... more PURPOSE: Morning rounds in the intensive care unit (ICU) enables multidisciplinary providers to interact and exchange information regarding patient care. ICU rounds are characterized by unique challenges including high acuity illness, frequent interruptions and processing of large quantities of highly dynamic data. These intersecting features complicate attempts to reliably characterize the structure and function of ICU rounds. Most existing studies have surveyed rounds participants, typically outside of the ICU setting. The aim of this study is to develop and validate a rounding observational tool that could be deployed in a working ICU environment by medically trained observers. METHODS: Investigators designed a survey inquiring about ICU rounding practice and distributed it to all members of the multidisciplinary rounding team in a tertiary teaching hospital. Seventy five surveys were collected for a response rate of 71.4%. Answers were grouped thematically and used as a reference to define 13 discrete rounding tasks in three defined locations (bedside, outside room, remote). Specific definitions and standard of operation for each task were vetted by an expert group and integrated into a web-based tool with multiple timer/event interfaces. After initial training sessions the final version of the tool was calibrated and interobserver variability was calculated. RESULTS: Over a two month period two independent, trained observers performed 16 paired observations of individual providers during 27 hours of ICU rounds. Interobserver variability was assessed showing good to excellent task categorizations (Kappa 0.87). Associated Bland-Altman plots showed consistent agreement of major provider's specific task duration, such as presentation (p=0.48, mean difference-0.02), discussion (p=0.21, mean difference-0.99), data gathering (p= 0.15, mean difference-0.39) CONCLUSIONS: This novel observation tool for ICU rounds provides a reliable method to record real time performance of common ICU rounding tasks by multidisciplinary providers. CLINICAL IMPLICATIONS: The observation tool will be used to observe rounding practice in various ICUs in order to characterize the process and to develop strategies and interventions to improve the efficiency of ICU rounds.
Adverse events and medical errors (AEs/MEs) are more likely to occur in the intensive care unit (... more Adverse events and medical errors (AEs/MEs) are more likely to occur in the intensive care unit (ICU). Information about the incidence and outcomes of such events is conflicting. A systematic review and meta-analysis were conducted to examine the effects of MEs/AEs on mortality and hospital and ICU lengths of stay among ICU patients. Potentially eligible studies were identified from 4 major databases. Of 902 studies screened, 12 met the inclusion criteria, 10 of which are included in the quantitative analysis. Patients with 1 or more MEs/AEs (vs no MEs/AEs) had a nonsignificant increase in mortality (odds ratio = 1.5; 95% confidence interval [CI] = 0.98-2.14) but significantly longer hospital and ICU stays; the mean difference (95% CI) was 8.9 (3.3-14.7) days for hospital stay and 6.8 (0.2-13.4) days for ICU. The ICU environment is associated with a substantial incidence of MEs/AEs, and patients with MEs/AEs have worse outcomes than those with no MEs/AEs.
Critical care delivery is a complex, expensive, error prone, medical specialty and remains the fo... more Critical care delivery is a complex, expensive, error prone, medical specialty and remains the focal point of major improvement efforts in healthcare delivery. Various modeling and simulation techniques offer unique opportunities to better understand the interactions between clinical physiology and care delivery. The novel insights gained from the systems perspective can then be used to develop and test new treatment strategies and make critical care delivery more efficient and effective. However, modeling and simulation applications in critical care remain underutilized. This article provides an overview of major computer-based simulation techniques as applied to critical care medicine. We provide three application examples of different simulation techniques, including a) pathophysiological model of acute lung injury, b) process modeling of critical care delivery, and c) an agent-based model to study interaction between pathophysiology and healthcare delivery. Finally, we identify ...
Although tranexamic acid is used to reduce bleeding after cardiac surgery, there is large variati... more Although tranexamic acid is used to reduce bleeding after cardiac surgery, there is large variation in the recommended dose, and few studies of plasma concentrations of the drug during cardiopulmonary bypass (CPB) have been performed. The plasma tranexamic acid concentration reported to inhibit fibrinolysis in vitro is 10 microg/mL. Twenty-one patients received an initial dose of 10 mg/kg given over 20 min followed by an infusion of 1 mg. kg(-1). h(-1) via a central venous catheter. Two patients were removed from the study secondary to protocol violation. Perioperative plasma tranexamic acid concentrations were measured with high-performance liquid chromatography. Plasma tranexamic acid concentrations (microg/mL; mean +/- SD [95% confidence interval]) were 37.4 +/- 16.9 (45.5, 29.3) after bolus, 27.6 +/- 7.9 (31.4, 23.8) after 5 min on CPB, 31.4 +/- 12.1 (37.2, 25.6) after 30 min on CPB, 29.2 +/- 9.0 (34.6, 23.8) after 60 min on CPB, 25.6 +/- 18.6 (35.1, 16.1) at discontinuation of tranexamic acid infusion, and 17.7 +/- 13.1 (24.1, 11.1) 1 h after discontinuation of tranexamic acid infusion. Four patients with renal insufficiency had increased concentrations of tranexamic acid at discontinuation of the drug. Repeated-measures analysis revealed a significant main effect of abnormal creatinine concentration (P = 0.02) and time (P < 0.001) on plasma tranexamic acid concentration and a significant time x creatinine concentration interaction (P < 0.001). A 10 mg/kg initial dose of tranexamic acid followed by an infusion of 1 mg.kg(-1).h(-1)produced plasma concentrations throughout the cardiopulmonary bypass period sufficient to inhibit fibrinolysis in vitro. The dosing of tranexamic acid may require adjustment for renal insufficiency.
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