David C. Stockwell

Quality and Safety in the Intensive Care Unit

Ensuring patient safety is becoming increasingly important for intensive care unit practitioners. The intensive care unit is particularly prone to medical errors because of the complexity of the patients, interdependence of the practitioners, and dependence on team functioning. This review provides historical perspectives, research foundations, and a practical “how to” guide to improving care in the intensive care unit. It also considers the organizational structure, the processes of care, and the occurrence of adverse outcomes in this setting. Effective intensive care unit quality and safety programs capitalize on institutional resources and have multidisciplinary input with clear leadership, input from quality improvement initiatives, a responsible yet nonpunitive culture, and data-driven assessment and monitoring to reduce medical errors. Intensive care unit practitioners need to capitalize on the benefits that patients and their families bring to the patient safety discourse. This provides opportunities for better understanding the risks of the intensive care unit and improving the consent process.

Leadership structures in emergency care settings: A study of two trauma centers

BACKGROUNDnTrauma resuscitation involves multidisciplinary teams under surgical leadership in most US trauma centers. Because many trauma centers have also incorporated emergency department (ED) physicians, shared and cross-disciplinary leadership structures often occur. Our study identifies leadership structures and examines the effects of cross-disciplinary leadership on trauma teamwork.nnnMETHODSnWe conducted an ethnographic study at two US Level-1 trauma centers, one of which is a dedicated pediatric trauma center. We used observation, videotaping and interviews to contextualize and classify leadership structures in trauma resuscitation. Leadership structures were evaluated based on three dimensions of team performance: defined leadership, likelihood of conflict in decision making, and appropriate care.nnnFINDINGSnWe identified five common leadership structures, grouped under two broad leadership categories: solo decision-making and intervening models within intra-disciplinary leadership; intervening, parallel, and collaborative models within cross-disciplinary leadership.nnnCONCLUSIONnMost important weaknesses of different leadership structures are manifested in inefficient teamwork or inappropriate patient care. These inefficiencies are particularly problematic when leadership is shared between physicians from different disciplines with different levels of experience, which often leads to conflict, reduces teamwork efficiency and lowers the quality of care. We discuss practical implications for technology design.

Acute harm: unplanned extubations and cardiopulmonary resuscitation in children and neonates

Dear Editor, Invasive mechanical ventilation is a common therapy used for children and infants in the intensive care unit (ICU). The impact of unplanned extubation (UE) on morbidity and mortality in adults is well described [1, 2]. There remains a paucity of data related to the cardiovascular morbidity associated with UE events in children. Following review and approval by the institutional review board in accordance and compliance with international ethics standards, we performed a retrospective database review of all UE events in patients admitted to the neonatal, pediatric or cardiac ICU at our institution between July 2011 and December 2012. UE was defined as the removal of an endotracheal tube in a mechanically ventilated patient which was not directed or ordered by a licenced independent practitioner. Cardiovascular collapse was defined as the need for cardiopulmonary resuscitation (e.g., external chest compressions) or circulatory dysfunction immediately following the UE event. Patients with tracheostomies were excluded from our analysis. Preliminary data were presented at the Pediatric Academic Societies’ and Asian Society for Pediatric Research Joint Meeting in Denver, Colorado in 2011 [3]. There were 119 UE events involving 95 unique patients, and the UE rate (events/100 ventilator days) was 0.5. Cardiovascular collapse occurred in 24 events (20 %), of which 20 involved initiation of cardiopulmonary resuscitation. Four events were characterized by circulatory dysfunction requiring immediate re-intubation without initiation of cardiopulmonary resuscitation. There was no immediate mortality associated with these events. We compared UE event characteristics stratified by presence or absence of cardiovascular collapse (Table 1). Immediate re-intubation was performed in 75 (63 %) events and was more likely in patients with cardiovascular collapse (p = 0.01). Cardiovascular collapse was more likely in younger patients (p = 0.048). It has been recognized for some time that UE carries with it significant morbidity increasing the risk of nosocomial infection and length of mechanical ventilation and ICU stay [1]. This is the first study that we are aware of that assesses the frequency of cardiovascular morbidity associated with UE in children. While much of the cardiovascular morbidity occurred in our neonatal population, our data suggest that unplanned extubations in critically ill children and neonates can lead to previously unrecognized morbidity. Despite recent advances in cardiopulmonary resuscitation and extracorporeal membrane oxygenation, in-hospital cardiac arrest portends poor outcomes with survival to discharge rates hovering around 25 % [4]. Our study is limited by the lack of long-term followup data to assess the impact of UE on mortality. However, our data do suggest there is potential for increased mortality associated with UE events. In conclusion, the frequency of cardiovascular morbidity in children

Patient handoffs: Delivering content efficiently and effectively is not enough

BACKGROUNDnThe transfer of care from one provider to another is fraught with potential failures. Unfortunately the consequences of a poorly conducted patient handoff can be quite high. In the last five years there have been many descriptions of this problem as well as suggested solutions. Commonly authors have focused on utilization of a formatted tool for the off-going provider to help improve patient handoffs. While this is certainly a requirement for a high quality transfer of care, it is not the only needed component.nnnOBJECTIVESnWe seek to describe a novel approach to handoffs and focus on the early findings from our pilot projects.nnnMETHODSnThe handoff typically involves two clinicians; an off-going or sending provider and an oncoming or receiving provider, there are therefore dual responsibilities in performing a high quality handoff. The off-going provider should structure their patient handoff in an easily assimilable format as earlier work has described. However a high quality handoff also needs to set the expectation that the oncoming provider must be certain that they have heard the relevant patient information. Therefore a tool to assist with this process is warranted. We describe our early experience of utilization of a structured handoff receiver tool.nnnRESULTSnClinicians report higher quality handoffs as a result of the addition of the dual responsibility handoff. Use of the I-5 Tool improved transfer of care. Also early results suggest that there are failures in care that would have occurred without this intervention.nnnCONCLUSIONSnEarly results from pilot testing reveal after designing and testing the dual responsibility model that patient handoffs are increasingly successful and more reliable.

Application of a modified microbiologic criterion for identifying pediatric ventilator-associated pneumonia

BACKGROUNDnPrevention of ventilator-associated pneumonia (VAP) is a major patient safety goal, but accurate identification of VAP in pediatric patients remains challenging.nnnMETHODSnWe performed a retrospective cohort study to demonstrate feasibility of endotracheal culture and Grams stain to support VAP diagnosis. Pediatric intensive care unit and cardiac intensive care unit patients with ≥ 1 endotracheal specimen having growth of ≥ 1 organism in conjunction with moderate/many polymorphonuclear leukocytes (ie, the modified microbiologic criterion) were included. Medical records were reviewed for presence/absence of clinical and radiographic Centers for Disease Control and Prevention (CDC) criteria for VAP. Antimicrobial use data were collected before and after culture results were known.nnnRESULTSnOf 102 patients meeting inclusion criteria, 28% (n = 28) also met both clinical and radiographic CDC criteria for VAP (ie, diagnosis of PNU2). An additional 63% (n = 64) met clinical (36%; n = 37) or radiographic (27%; n = 27) criteria, but not both. Ten patients (9%) had neither clinical nor radiographic criteria for VAP. The majority (63%; n = 64) were receiving antibiotics at time of endotracheal specimen collection. Culture identification resulted in altered antimicrobial therapy in 66% of patients (n = 67).nnnCONCLUSIONSnOur study demonstrates the feasibility of endotracheal Grams stain and culture for diagnosis of pediatric VAP that could potentially standardize accurate surveillance and management of pediatric VAP.

Effects of designated leadership and team-size on cardiopulmonary resuscitation: The Basel-Washington SIMulation (BaWaSim) trial

Objective: During cardiopulmonary resuscitation (CPR), it remains unclear whether designating an individual person as team leader compared with emergent leadership results in better team performance. Also, the effect of CPR team size on team performance remains understudied. Methods: This randomized‐controlled trial compared designated versus emergent leadership and size of rescue team (3 vs 6 rescuers) on resuscitation performance. Results: We included 90 teams with a total of 408 students. No difference in mean (±SD) hands‐on time (seconds) were observed between emergent leadership (106 ± 30) compared to designated leadership (103 ± 27) groups (adjusted difference − 2.97 (95%CI ‐15.75 to 9.80, p = 0.645), or between smaller (103 ± 30) and larger teams (106 ± 26, adjusted difference 3.53, 95%CI ‐8.47 to 15.53, p = 0.56). Emergent leadership groups had a shorter time to circulation check and first defibrillation, but the quality of CPR based on arm and shoulder position was lower. No differences in CPR quality measures were observed between smaller and larger teams. Conclusions: Within this international US/Swiss trial, leadership designation and larger team size did not improve hands‐on time, but emergent leadership teams initiated defibrillation earlier. Improvements in performance may be more likely to be achieved by optimization of emergent leadership than increasing the size of cardiac arrest teams.

Automatically Getting Better

The Children’s National informatics and technology team built an electronic reporting tool which identifies adverse events occurring throughout their hospital based upon queries of their electronic health record (EHR) system, such as abnormal lab data (e.g. low glucose) or antidote medications prescribed in the event of a medical problem (e.g. Naloxone). This daily report, termed the Automated Adverse Event Detection (AAED), is monitored by a nurse who analyzes each abnormal item to determine its level of harm and whether it was preventable. The appropriate physicians and managers then study this information to determine how they can improve their processes and avoid similar adverse events in the future. The review team may include the clinicians involved with the event as well as “trigger-specific experts” (e.g. hypoglycemia cases are reviewed with endocrinologists, naloxone adverse events are reviewed with pain medicine experts).

Error Reporting Systems

The ability to detect errors in medicine is an important starting point for programmatic interventions aimed at improving patient safety. While information technology has the ability to improve many aspects of healthcare, the optimization of error reporting can ultimately improve error reduction because of the focus it brings to system defects.