Andre Carlos Kajdacsy-Balla Amaral

Knowledge translation interventions for critically ill patients: a systematic review*.

Objective:We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. Data Sources:We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. Study Selection:Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. Data Extraction:Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. Data Synthesis:From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes. Conclusions:Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.

Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial

Background: Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care. Methods: Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents’ physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed. Results: We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents’ sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents’ somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents’ knowledge and decision-making worst with the 16-hour schedule. Interpretation: Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents’ symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. Trial registration: ClinicalTrials.gov, no. NCT00679809.

The future of critical care.

Purpose of reviewThis review will examine the current scenario of critical care medicine and describe trends for the future. Recent findingsCritical care is facing increasing demands due to an aging population and the relative lack of intensivists. Quality and healthcare costs are becoming day-to-day issues. The future will see an increasing use of protocols, virtual consultations, and regionalized care for more complex and common diseases such as trauma and acute lung injury. Intensivists will be skeptical due to difficulties in demonstrating benefits of any new drug, ventilator, monitor, or laboratory test, when added to basic, life-saving treatments. We do not believe that a ‘magic bullet’ is soon to come, and emphasis will be placed on cost restraining. Computers will have an increasing presence in critical care, now eased by a user group that is increasingly adept at using them. However, ICUs will still rely on human resource, making the myth of a fully automated ICU bed unlikely. SummaryThe future of ICU will rely on management and teamwork. The costs of critical care will be restrained through the use of better management, guidelines, and skepticism regarding new technologies and drugs. Policy makers will help society build better strategies for critical care services.

It's Parallel Universes: An Analysis of Communication Between Surgeons and Intensivists.

Objectives:The intensivist-led model of ICU care requires surgical consultants and the ICU team to collaborate in the care of ICU patients and to communicate effectively across teams. We sought to characterize communication between intensivists and surgeons and to assess enablers and barriers of effective communication. Design:Qualitative interview study. An inductive data analysis approach was taken. Setting:Seven intensivist-led ICUs in four academic hospitals. Subjects:Surgeons (attendings and residents), intensivists (attendings and residents), and ICU nurses participating in the care of surgical patients in the ICU. Interventions:None. Measurements and Main Results:Communication enablers and barriers existed at two distinct levels: 1) organizational and 2) cultural. At an organizational level, participants identified that formally sanctioned communication structures and processes often acted as barriers to communication. Participants had developed informal strategies to improve communication. At a cultural level, surgical and ICU participants often expressed conflicting perspectives regarding patient ownership, scope of practice, and clinical expertise. Conclusions:Major barriers to optimal communication between surgical and ICU teams exist in the intensivist-led ICU environment. Many are related to the structures and processes meant to facilitate communication across teams and others to how some aspects of care in the ICU are conceptualized. Multiple actionable opportunities exist to improve communication in the intensivist-led ICU.

Patient and Organizational Factors Associated With Delays in Antimicrobial Therapy for Septic Shock

Objectives:To identify clinical and organizational factors associated with delays in antimicrobial therapy for septic shock. Design:In a retrospective cohort of critically ill patients with septic shock. Setting:Twenty-four ICUs. Patients:A total of 6,720 patients with septic shock. Interventions:None. Measurements and Main Results:Higher Acute Physiology Score (+24 min per 5 Acute Physiology Score points; p < 0.0001); older age (+16 min per 10 yr; p < 0.0001); presence of comorbidities (+35 min; p < 0.0001); hospital length of stay before hypotension: less than 3 days (+50 min; p < 0.0001), between 3 and 7 days (+121 min; p < 0.0001), and longer than 7 days (+130 min; p < 0.0001); and a diagnosis of pneumonia (+45 min; p < 0.01) were associated with longer times to antimicrobial therapy. Two variables were associated with shorter times to antimicrobial therapy: community-acquired infections (–53 min; p < 0.001) and higher temperature (–15 min per 1°C; p < 0.0001). After adjusting for confounders, admissions to academic hospitals (+52 min; p< 0.05), and transfers from medical wards (medical vs surgical ward admission; +39 min; p < 0.05) had longer times to antimicrobial therapy. Admissions from the emergency department (emergency department vs surgical ward admission, –47 min; p< 0.001) had shorter times to antimicrobial therapy. Conclusions:We identified clinical and organizational factors that can serve as evidence-based targets for future quality-improvement initiatives on antimicrobial timing. The observation that academic hospitals are more likely to delay antimicrobials should be further explored in future trials.

Driving Pressure and Hospital Mortality in Patients Without ARDS: A Cohort Study

Background Driving pressure (&Dgr;P) is associated with mortality in patients with ARDS and with pulmonary complications in patients undergoing general anesthesia. Whether &Dgr;P is associated with outcomes of patients without ARDS who undergo ventilation in the ICU is unknown. Our objective was to determine the independent association between &Dgr;P and outcomes in mechanically ventilated patients without ARDS on day 1 of mechanical ventilation. Methods This was a retrospective analysis of a cohort of 622 mechanically ventilated adult patients without ARDS on day 1 of mechanical ventilation from five ICUs in a tertiary center in the United States. The primary outcome was hospital mortality. The presence of ARDS was determined using the minimum daily Pao2 to Fio2 (PF) ratio and an automated text search of chest radiography reports. The data set was validated by first testing the model in 543 patients with ARDS. Results In patients without ARDS on day 1 of mechanical ventilation, &Dgr;P was not independently associated with hospital mortality (OR, 1.01; 95% CI, 0.97‐1.05). The results of the primary analysis were confirmed in a series of preplanned sensitivity analyses. Conclusions In this cohort of patients without ARDS on day 1 of mechanical ventilation and within the limits of ventilatory settings normally used by clinicians, &Dgr;P was not associated with hospital mortality. This study also confirms the association between &Dgr;P and mortality in patients with ARDS not enrolled in a trial and in hypoxemic patients without ARDS.

Communication and Culture in the Surgical Intensive Care Unit Boundary Production and the Improvement of Patient Care

This ethnography explores communication around critically ill surgical patients in three surgical intensive care units (ICUs) in Canada. A boundary framework is used to articulate how surgeons’, intensivists’, and nurses’ communication practices shape and are shaped by their respective disciplinary perspectives and experiences. Through 50 hours of observations and 43 interviews, these health care providers are found to engage in seven communication behaviors that either mitigate or magnify three contested symbolic boundaries: expertise, patient ownership, and decisional authority. Where these boundaries are successfully mitigated, experiences of collaborative, high-quality patient care are produced; by contrast, boundary magnification produces conflict and perceptions of unsafe patient care. Findings reveal that high quality and safe patient care are produced through complex social and cultural interactions among surgeons, intensivists, and nurses that are also expressions of knowledge and power. This enhances our understanding of why current quality improvement efforts targeting communication may be ineffective.

Timing of Antimicrobial Therapy after Identification of Ventilator-Associated Condition Is Not Associated with Mortality in Patients with Ventilator-Associated Pneumonia: A Cohort Study

Purpose Delays in antimicrobial therapy increase mortality in ventilator-associated pneumonia (VAP). The more objective ventilator-associated complications (VAC) are increasingly used for quality reporting. It is unknown if delays in antimicrobial administration, after patients meet VAC criteria, leads to worse outcomes. Materials and Methods Cohort of 81 episodes of antimicrobial treatment for VAP. We compared mortality, superinfections and treatment failures conditional on the timing of identification of VAC. Results 60% of patients with VAC had an identifiable episode at least 48 before the initiation of antimicrobials. Antimicrobial administration after the identification of VAC was not associated with intensive care unit (ICU) mortality (OR 0.71, 95% CI 0.11–4.48, p = 0.701) compared to immediate antimicrobial administration. Similarly, the risk of treatment failure or superinfection was not affected by the timing of administration of antimicrobials in VAC (HR 0.95, 95% CI 0.42–2.19, p = 0.914). Conclusions We observed no signal of harm associated with the timing to initiate antimicrobials after the identification of a VAC. The identification of VAC should not lead clinicians to start antimicrobials before a diagnosis of VAP can be established.

Effects of increasing compliance with minimal sedation on duration of mechanical ventilation: a quality improvement intervention

IntroductionIn the past two decades, healthcare adopted industrial strategies for process measurement and control. In the industry model, care is taken to avoid minimal deviations from a standard. In healthcare there is scarce data to support that a similar strategy can lead to better outcomes. Briefly, when compliance is high, further attempts to improve uptake of a process are seldom made. Our intensive care unit (ICU) improved the compliance with minimizing sedation from a high baseline of 80.4% (95% CI: 66.9 to 90.2) to 96.2% (95% CI: 95.2 to 97.0) 12 months after a quality improvement initiative. We sought to measure whether this minute improvement in compliance led to a reduction in duration of mechanical ventilation.MethodsWe collected data on compliance with the process during 12 months. A trained data collector abstracted data from charts every other day. Our database contains data for length of mechanical ventilation, mortality, type of admission, and acute physiology and chronic health evaluation (APACHE) II scores for the 12 months before and after the process improvement.To control for secular trends we used an interrupted-time series with adjustment for auto-correlation. We calculated the expected length of mechanical ventilation on each month by the end of the intervention period, and calculated the fitted value for the post-intervention months.ResultsWe included 1556 patients. There was an immediate effect of the intervention (regression coefficient = -0.129, P value < 0.001) and the secular trend was a determinant of length of mechanical ventilation (regression coefficient = 0.010, P value = 0.004). The trend post-intervention was not significant (regression coefficient = 0.004, P value = 0.380).The relative change in the length of mechanical ventilation was 14.5% (IQR 13.8% to 15.8%) and the total expected decrease in mechanical ventilation days was 502.7 days (95% CI 300.9 to 729.1) over one year.ConclusionsIn a system already working at high levels of compliance, outcomes can still be improved. Our intervention was successful in reducing the length of mechanical ventilation. ICUs should have a process of quality assurance in place to provide constant monitoring of key quality of care processes and correct deviations from the proposed standard.

Rapid response teams: a diagnostic dilemma

The implementation of rapid response teams (RRTs), also known as medical emergency teams, across the world has happened in parallel with the research to assess their effectiveness.1 The development of RRTs occurred due to observations that associated signs and symptoms are often present hours or days before clear clinical deterioration in the majority of patients.2 By assessing these patients early, RRTs would presumably prevent progression to cardiopulmonary arrest. The article by Akhtar et al assesses the performance of a RRT in three NHS Acute Hospitals in England within a single NHS Trust, with a particular focus on the variability in duration and diagnostic accuracy of the call placed to trigger the RRT.3 Examining 426 RRT activations, the authors identified significant variation in the duration of the call placed, with the call taking anywhere from 6 s to 92 s. The authors then examined the recording to identify the causes of a longer call time, concluding that a substantial source of delay was confusion over whether to identify a situation as a medical emergency or a cardiac arrest. This leads to the question of whether RRTs should act separate from, or as an extension of, ‘code’ teams, which primarily focus on resuscitation of patients who have already had a cardiac arrest. Early studies of RRTs focused on decreasing the frequency of cardiac arrests, suggesting that RRTs were originally created to only respond to a medical emergency before the onset of an arrest. Most of these data came from single-centre studies that used a ‘before–after’ design, comparing outcomes for the patients cared for before implementation of the RRT with outcomes …