Dominique Piquette

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.

Interprofessional intensive care unit team interactions and medical crises: A qualitative study

Research has suggested that interprofessional collaboration could improve patient outcomes in the intensive care unit (ICU). Maintaining optimal interprofessional interactions in a setting where unpredictable medical crises occur periodically is however challenging. Our study aimed to investigate the perceptions of ICU health care professionals regarding how acute medical crises affect their team interactions. We conducted 25 semi-structured interviews of ICU nurses, staff physicians, and respiratory therapists. All interviews were audio-taped and transcribed, and the analysis was undertaken using an inductive thematic approach. Our data indicated that the nature of interprofessional interactions changed as teams passed through three key temporal periods around medical crises. During the “pre-crisis period”, interactions were based on the mutual respect of each others expertise. During the “crisis period”, hierarchical interactions were expected and a certain lack of civility was tolerated. During the “post-crisis period”, divergent perceptions emerged amongst health professionals. Post-crisis team dispersion left the nurses with questions and emotions not expressed by other team members. Nurses believed that systematic interprofessional feedback sessions held immediately after a crisis could address some of their needs. Further research is needed to establish the possible benefits of strategies addressing ICU health care professionals specific needs for interprofessional feedback after a medical crisis.

Stressful intensive care unit medical crises: how individual responses impact on team performance.

Background: Intensive care units (ICUs) are recognized as stressful environments. However, the conditions in which stressors may affect health professionals’ performance and well-being and the conditions that potentially lead to impaired performance and staff psychological distress are not well understood. Objectives: The purpose of this study was to determine healthcare professionals’ perceptions regarding the factors that lead to stress responses and performance impairments during ICU medical crises. Design: A qualitative study in a university-affiliated ICU in Canada. Methodology: We conducted 32 individual semistructured interviews of ICU nurses, staff physicians, residents, and respiratory therapists in a university-affiliated hospital. The transcripts of the audiotaped interviews were analyzed using an inductive thematic methodology. Results: Increased workload, high stakes, and heavy weight of responsibility were recognized as common stressors during ICU crises. However, a high level of individual and team resources available to face such demands was also reported. When the patient’s condition was changing or deteriorating unpredictably or when the expected resources were unavailable, crises were assessed by some team members as threatening, leading to individual distress. Once manifested, this emotional distress was strongly contagious to other team members. The ensuing collective anxiety was perceived as disruptive for teamwork and deleterious for individual and collective performance. Conclusions: Individual distress reactions to ICU crises occurred in the presence of unexpectedly high demands unmatched by appropriate resources and were contagious among other team members. Given the high uncertainty surrounding many ICU medical crises, strategies aimed at preventing distress contagion among ICU health professionals may improve team performance and individual well-being.

Impact of Acute Stress on Resident Performance During Simulated Resuscitation Episodes: A Prospective Randomized Cross-Over Study

Background: Medical trainees have identified stress as an important contributor to their medical errors in acute care environments. Purposes: The objective of this study was to determine if the addition of acute stressors to simulated resuscitation scenarios would impact on residents’ simulated clinical performance. Methods: Fifty-four residents completed a control and a high-stress simulated scenario on separate visits. Stress measures were collected before and after scenarios. Two assessors independently evaluated residents’ videotaped performance. Results: Both control and high-stress scenarios triggered significant stress responses among participants; however, stress responses were not significantly different between control and high-stress conditions. No difference in performance was found between control and high-stress conditions (F value = 2.84, p = .098). Conclusions: Residents exposed to simulated resuscitation scenarios experienced significant stress responses irrespective of the presence of acute stressors during these scenarios. This anticipatory stressful response could impact on resident learning and performance and should be further explored.

E-learning optimization: the relative and combined effects of mental practice and modeling on enhanced podcast-based learning—a randomized controlled trial

Enhanced podcasts increase learning, but evidence is lacking on how they should be designed to optimize their effectiveness. This study assessed the impact two learning instructional design methods (mental practice and modeling), either on their own or in combination, for teaching complex cognitive medical content when incorporated into enhanced podcasts. Sixty-three medical students were randomised to one of four versions of an airway management enhanced podcast: (1) control: narrated presentation; (2) modeling: narration with video demonstration of skills; (3) mental practice: narrated presentation with guided mental practice; (4) combined: modeling and mental practice. One week later, students managed a manikin-based simulated airway crisis. Knowledge acquisition was assessed by baseline and retention multiple-choice quizzes. Two blinded raters assessed all videos obtained from simulated crises to measure the students’ skills using a key-elements scale, critical error checklist, and the Ottawa global rating scale (GRS). Baseline knowledge was not different between all four groups (pxa0=xa00.65). One week later, knowledge retention was significantly higher for (1) both the mental practice and modeling group than the control group (pxa0=xa00.01; pxa0=xa00.01, respectively) and (2) the combined mental practice and modeling group compared to all other groups (all psxa0=xa00.01). Regarding skills acquisition, the control group significantly under-performed in comparison to all other groups on the key-events scale (all psxa0≤xa00.05), the critical error checklist (all psxa0≤xa00.05), and the Ottawa GRS (all psxa0≤xa00.05). The combination of mental practice and modeling led to greater improvement on the key events checklist (pxa0=xa00.01) compared to either strategy alone. However, the combination of the two strategies did not result in any further learning gains on the two other measures of clinical performance (all psxa0>xa00.05). The effectiveness of enhanced podcasts for knowledge retention and clinical skill acquisition is increased with either mental practice or modeling. The combination of mental practice and modeling had synergistic effects on knowledge retention, but conveyed less clear advantages in its application through clinical skills.

Effects of clinical supervision on resident learning and patient care during simulated ICU scenarios.

Objectives:Closer supervision of residents’ clinical activities has been promoted to improve patient safety, but may additionally affect resident participation in patient care and learning. The objective of this study was to determine the effects of closer supervision on patient care, resident participation, and the development of resident ability to care independently for critically ill patients during simulated scenarios. Design:This quantitative study represents a component of a larger mixed-methods study. Residents were randomized to one of three levels of supervision, defined by the physical proximity of the supervisor (distant, immediately available, and direct). Each resident completed a simulation scenario under the supervision of a critical care fellow, immediately followed by a modified scenario of similar content without supervision. Setting:The simulation center of a tertiary, university-affiliated academic center in a large urban city. Subjects:Fifty-three residents completing a critical care rotation and 24 critical care fellows were recruited between April 2009 and June 2010. InterventionsNone. Measurements and Main Results:During the supervised scenarios, lower team performance checklist scores were obtained for distant supervision compared with immediately available and direct supervision (mean [SD], direct: 72% [12%] vs immediately available: 77% [10%] vs distant: 61% [11%]; p = 0.0013). The percentage of checklist items completed by the residents themselves was significantly lower during direct supervision (median [interquartile range], direct: 40% [21%] vs immediately available: 58% [16%] vs distant: 55% [11%]; p = 0.005). During unsupervised scenarios, no significant differences were found on the outcome measures. Conclusions:Care delivered in the presence of senior supervising physicians was more comprehensive than care delivered without access to a bedside supervisor, but was associated with lower resident participation. However, subsequent resident performance during unsupervised scenarios was not adversely affected. Direct supervision of residents leads to improved care process and does not diminish the subsequent ability of residents to function independently.

Impact of intensivist staffing on patient care and trainee education: a Canadian perspective.

physician (16, 17). Conditions to conduct research and protocols must be fostered, as well the introduction of new technologies and monitoring systems. Although these tasks may increase stress and eventually to burnout, surprisingly, such burnout in intensivists has not been linked to the quality of patient care, but rather to organizational aspects, such as workload (number of night shifts, duration of resting periods, perceived high responsibility in bed allocation, others) (18, 19), and to impaired relationships with colleagues (18). Intensivists are a valued and scarce medical resource, in increasing shortage (20). It is in the best interest of the scientific community to recommend to the health authorities the adoption of policies to preserve intensivists who are in the system, but also to attract young physicians that are interested in critical care but have important reservations regarding intensivists’ lifestyle (21). Possible measures to improve working conditions might include, but are not limited to, replacing 24-hour shifts by equivalent but shorter periods, providing sufficient leisure hours and adequate salaries, and generating conditions for earlier retirement. The beneficial effect of the full and continued presence of highly satisfied personnel in the ICU will be certainly translated to patient care.

Clinical supervision and learning opportunities during simulated acute care scenarios

Closer clinical supervision has been increasingly promoted to improve patient care. However, the continuous bedside presence of supervisors may threaten the model of progressive independence traditionally associated with effective clinical training. Studies have shown favourable effects of closer supervision on trainees learning, but have not paid specific attention to the learning processes involved.

Model of interactive clinical supervision in acute care environments. Balancing patient care and teaching.

RATIONALEnProgressive trainee autonomy is considered essential for clinical learning, but potentially harmful for patients. How clinical supervisors and medical trainees establish progressive levels of autonomy in acute care environments without compromising patient safety is largely unknown.nnnOBJECTIVESnTo explore how bedside interactions among supervisors and trainees relate to trainee involvement in patient care and to clinical oversight.nnnMETHODSnWe conducted a qualitative study based on constructivist grounded theory methodology. We used participant observation for our data collection. We observed the overt teaching interactions among trainees and staff physicians in the critical care units of two university-affiliated hospitals during 74 acute care episodes. Our analysis led to the elaboration of a theoretical model of clinical supervision.nnnMEASUREMENTS AND MAIN RESULTSnA model of interactive clinical supervision is proposed on the basis of three themes: engaging without enactment, sharing care with support, and caring independently with feedback. Each theme regroups different teaching interactions. Engaging in monologues and dialogues about patient care and facilitating hands-off care provision involved progressive levels of trainee involvement without risk for patients. Facilitating hands-on provision of care and providing support-in-action encouraged further trainee involvement with limited risks for patients. Providing feedback-on-action created additional learning opportunities based on trainee independent involvement in clinical activities.nnnCONCLUSIONSnEngaging in teaching interactions during acute care episodes allows trainees to exercise progressive autonomy and supervisors to provide adequate clinical oversight. Our model of interactive clinical supervision can inform faculty development initiatives. Learning outcomes resulting from different levels of trainee autonomy should be further explored.

Balancing care and teaching during clinical activities: 2 contexts, 2 strategies

PURPOSEnThe goal of this study was to better understand how clinical supervisors integrate teaching interactions with medical trainees into 2 types of clinical activities in the critical care setting: multidisciplinary rounds and medical crises.nnnMETHODSnWe conducted a qualitative, observational study based on an ethnographic approach. We observed the teaching interactions among clinical supervisors and medical trainees during 12 multidisciplinary rounds and 74 medical crises in 2 academic hospitals. Grounded theory methods (theoretical sampling and saturation, inductive thematic coding, and constant comparison) were used to analyze data.nnnRESULTSnTwo models of integration of teaching interactions into clinical activities are described: the in series model, typical of multidisciplinary rounds and characterized by well-structured learning bubbles uninterrupted by patient care, and the in parallel model, common during medical crises and involving multiple, short learning flashes intricately related to and frequently interrupted by patient care. By adopting a model over the other, supervisors appeared to adapt to 2 contexts that differed in terms of priority, supervisors understanding of events, and social context of interactions. Each model presented complementary opportunities and limitations for learning.nnnCONCLUSIONSnModern views of medical apprenticeship and clinical teaching need to take into account the specific clinical context in which learning occurs. Teaching interactions that differ in structure and content in response to changing clinical circumstances could impact learning in unique ways. Learning outcomes resulting from different models of integration of teaching into clinical activities need to be further explored.