Christopher R. Dale

Improved Analgesia, Sedation, and Delirium Protocol Associated with Decreased Duration of Delirium and Mechanical Ventilation

RATIONALE Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics. METHODS This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and (3) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate. RESULTS Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P < 0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P < 0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P < 0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction in median duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen. CONCLUSIONS Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.

A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs.

PURPOSE Common labs such as a daily complete blood count or a daily basic metabolic panel represent possible waste and have been targeted by professional societies and the Choosing Wisely campaign for critical evaluation. We undertook a multifaceted quality-improvement (QI) intervention in a large community hospitalist group to decrease unnecessary common labs. METHODS The QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered as daily within the hospitalist group. We performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the 7-month intervention period. Demographic and clinical data were collected from the electronic medical record. The primary endpoint was number of common labs ordered per patient-day as estimated by a clustered multivariable linear regression model clustering by ordering hospitalist. Secondary endpoints included length of stay, hospital mortality, 30-day readmission, blood transfusion, amount of blood transfused, and laboratory cost per patient. RESULTS The baseline (n = 7824) and intervention (n = 5759) cohorts were similar in their demographics, though the distribution of primary discharge diagnosis-related groups differed. At baseline, a mean of 2.06 (standard deviation 1.40) common labs were ordered per patient-day. Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared to baseline (95% confidence interval [CI], 0.34 to 0.11; P < 0.01). There were nonsignificant reductions in hospital mortality in the intervention period compared to baseline (2.2% vs 1.8%, P = 0.1) as well as volume of blood transfused in patients who received a transfusion (127.2 mL decrease; 95% CI, -257.9 to 3.6; P = 0.06). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated

Hospital-Level Factors Associated with Report of Physical Activity in Patients on Mechanical Ventilation across Washington State

16.19 per admission or

A greater analgesia, sedation, delirium order set quality score is associated with a decreased duration of mechanical ventilation in cardiovascular surgery patients.

151,682 annualized (95% CI,

Navigational bronchoscopy with biopsy versus computed tomography-guided biopsy for the diagnosis of a solitary pulmonary nodule: a cost-consequences analysis.

119,746 to

Variation in Tracheal Reintubations Among Patients Undergoing Cardiac Surgery Across Washington State Hospitals

187,618). CONCLUSION Implementation of a multifaceted QI intervention within a community-based hospitalist group was associated with a significant, but modest, decrease in the number of ordered lab tests and hospital costs. No effect was seen on hospital length of stay, mortality, or readmission rate. This intervention suggests that a community-based hospitalist QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.

Association between hospital volume and network membership and an analgesia, sedation and delirium order set quality score: a cohort study

RATIONALE Use of physical and/or occupational therapy in the intensive care unit (ICU) is safe, feasible, and demonstrates improvements in functional status with early administration. Access to physical and/or occupational therapy in the ICU is variable, with little known regarding its use in community ICUs. OBJECTIVES Determine what proportion of hospitals across Washington State report use of physical activity in mechanically ventilated patients and investigate process of care factors associated with reported activity delivery. METHODS Cross-sectional telephone interview survey study of nurse managers in hospitals caring for patients on mechanical ventilation across Washington State in 2013. Survey responses were linked with hospital-level data available in the Washington State Department of Health Comprehensive Hospital Abstract Reporting System database. Chi-square testing was used to explore unadjusted associations between potential process of care factors and report on activity delivery. Two multivariable logistic regression models were developed to explore the association between presence of a mobility protocol and report on delivery of activity. MEASUREMENTS AND MAIN RESULTS We identified 54 hospitals caring for patients on mechanical ventilation; 47 participated in the survey (response rate, 85.5%). Nurse managers from 36 (76.6%) hospitals reported use of physical activity in patients on mechanical ventilation, with 22 (46.8%) reporting use of high-level physical activity (transferring to chair, standing or ambulating) and 24 (51.1%) reporting use in high-severity patients (patients requiring mechanical ventilation and/or vasopressors). Presence of a written ICU activity protocol (odds ratio [OR], 5.54; 95% confidence interval [CI], 1.60-19.18; P = 0.006), hospital volume (OR, 5.33; 95% CI, 1.54-18.48; P = 0.008), and academic affiliation (OR, 4.40; 95% CI, 1.23-15.63; P = 0.02) were associated with report of higher level activity. Presence of a written ICU activity protocol (OR, 6.00; 95% CI, 1.69-21.14; P = 0.005) and academic affiliation (OR, 4.50; 95% CI, 1.21-16.46; P = 0.02) were associated with report of delivery of physical activity to high-severity patients. CONCLUSIONS Nurse managers at three-fourths (76.6%) of eligible hospitals across Washington State reported use of physical activity in patients on mechanical ventilation. Hospital-level factors including hospital volume, academic affiliation, and presence of a mobility protocol were associated with report of higher level activity and delivery of activity to high-severity patients.

Navigational Bronchoscopy with Biopsy versus CT-guided Biopsy for the Diagnosis of a Solitary Pulmonary Nodule: A Cost-Consequences Analysis

Objective:Protocols and order sets for the delivery of analgesia, sedation, and delirium care of the critically ill, mechanically ventilated patient have been shown to improve outcomes but are not uniform in hospitals across geographic areas. The extent to which greater order set quality is associated with improved patient outcomes is not known. We hypothesized that cardiac surgery patients cared for at hospitals with a greater analgesia, sedation, and delirium order set quality score (more guideline-concordant order sets) would have a shorter average duration of mechanical ventilation. Design:Retrospective cohort study. Setting:All Washington State non-federal hospitals providing cardiac surgery. Patients:All mechanically ventilated cardiac surgery patients from January 1, 2008, until September 30, 2011. Interventions:None. Measurements and Main Results:We created a multivariable linear regression model to assess the relationship between a hospital’s pain, agitation and delirium order set quality, as assessed by an expert-validated order set quality score, and the average duration of mechanical ventilation of its cardiac surgery patients, independent of other hospital and patient factors. A total of 19,561 patients underwent cardiac surgery at 16 Washington state hospitals during the study period. The order set quality scores ranged from 4 to 19 with a mean of 11.8 ± 4.5. The mean duration of mechanical ventilation was 27.0 ± 196.6 hours. In the multivariable model, independent of other patient and hospital factors, a 1-point increase in the order set quality score was associated with a 3.3 ± 0.9 hour (p < 0.01) decrease in average duration of mechanical ventilation. Conclusions:Cardiac surgery hospitals with more guideline-adherent analgesia, sedation, and delirium order sets have patients with shorter mean durations of mechanical ventilation than hospitals with lower order set quality scores.

A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs: Multifaceted Hospitalist QI Intervention

Background:Solitary pulmonary nodules (SPNs) are frequent and can be malignant. Both computed tomography-guided biopsy and electromagnetic navigational bronchoscopy (ENB) with biopsy can be used to diagnose a SPN. A nondiagnostic computed tomography (CT)–guided or ENB biopsy is often followed by video-assisted thoracoscopic surgery (VATS) biopsy. The relative costs and consequences of these strategies are not known. Methods:A decision tree was created with values from the literature to evaluate the clinical consequences and societal costs of a CT-guided biopsy strategy versus an ENB biopsy strategy for the diagnosis of a SPN. The serial use of ENB after nondiagnostic CT-guided biopsy and CT-guided biopsy after nondiagnostic ENB biopsy were tested as alternate strategies. Results:In a hypothetical cohort of 100 patients, use of the ENB biopsy strategy on average results in 13.4 fewer pneumothoraces, 5.9 fewer chest tubes, 0.9 fewer significant hemorrhage episodes, and 0.6 fewer respiratory failure episodes compared with a CT-guided biopsy strategy. ENB biopsy increases average costs by

A multifaceted hospitalist quality improvement intervention

3719 per case and increases VATS rates by an absolute 20%. The sequential diagnostic strategy that combines CT-guided biopsy after nondiagnostic ENB biopsy and vice versa decreases the rate of VATS procedures to 3%. A sequential approach starting with ENB decreases average per case cost relative to CT-guided biopsy followed by VATS, if needed, by