Donna L. Agan

Facilitated sensemaking: a feasibility study for the provision of a family support program in the intensive care unit.

Family members of intensive care unit patients may develop anxiety, depression, and/or posttraumatic stress syndrome. Approaches to prevention are not well defined. Before testing preventive measures, it is important to evaluate which interventions the family will accept, use, and value. The purpose of this study was to evaluate the feasibility of an intervention for support for families of mechanically ventilated adults, grounded in a new midrange nursing theory titled “Facilitated Sensemaking.” Families were provided a kit of supplies and the primary investigator coached families on how to obtain information, interpret surroundings, and participate in care. Participants were asked to complete an adapted Critical Care Family Needs Inventory and Family Support Program evaluation. Family members of 30 patients consented to participate; 22 participants completed the surveys. Internal consistency reliability of the adapted Critical Care Family Needs Inventory was high (α = .96). Results validated the importance of informational needs and provided a score indicating the family members perception of how well each need was met, weighted by importance, which identified performance improvement opportunities for use by clinical managers. The program evaluation confirmed that families will use this format of support and find it helpful. Personal care supplies (eg, lotion, lip balm) were universally well received. Forty-two referrals to ancillary service were made. Operational issues to improve services were identified. As proposed in the Facilitated Sensemaking model, family members welcomed interventions targeted to help make sense of the new situation and make sense of their new role as caregiver. Planned supportive interventions were perceived as helpful.

Multidisciplinary team training to enhance family communication in the ICU.

Objectives:Current guidelines from the U.S. Society for Critical Care Medicine state that training in “good communication skills...should become a standard component of medical education and ... available for all ICU caregivers”. We sought to train multidisciplinary teams of ICU caregivers in communicating with the families of critically ill patients to improve staff confidence in communicating with families, as well as family satisfaction with their experiences in the ICU. Design:Pre- and postintervention design. Setting:Community hospital medical and surgical ICUs. Patients:All patients admitted to ICU during the two time periods. Intervention:Ninety-eight caregivers in multidisciplinary teams of five to eight individuals trained in a standardized approach to communicating with families of ICU patients using the Setup, Perception, Invitation, Knowledge, Emotions, Strategy (or Subsequent) (SPIKES) protocol followed by participation in a simulated family conference. Measurements:Staff confidence in communicating with family members of critically ill patients was measured immediately before and 6–8 weeks after training sessions using a validated tool. Family satisfaction using seven items measuring effectiveness of communication from the Family Satisfaction in the ICU (24) tool in surveys received from family members of 121 patients admitted to the ICU before and 121 patients admitted to the ICU after trainings was completed. Main Results:Using 46 matched pre- and postsurveys, staff confidence in communicating with family members of critically ill patients increased significantly (p < 0.001) in each of 21 separate measures. Family satisfaction with communication showed significant (p < 0.05 or better) improvement in three of seven individual items compared with those same items pretraining. There was no decline in any individual item. Conclusions:A simple intervention resulted in improvement in staff confidence, as well as in multiple measures of family satisfaction with communication. This intervention is easily reproduced.

Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination.

BACKGROUND Despite the future potential of using ultrasound stethoscopes to augment the bedside cardiac physical, few data exist on a general cardiovascular imaging protocol that can be taught to physicians on a perpetual basis as a curriculum in graduate medical education. METHODS During the past decade, we developed and integrated a cardiovascular limited ultrasound training program within the confines of an internal medicine residency. The evidence-based rationale for the exam, the teaching methods, and curriculum are delineated, and subsequent observations regarding program requirements, proficiency, and academic outcomes are explored. Analysis of variance and linear regression assessed for relationships between academic scores, chief resident selection, and gender to proficiency in ultrasound. RESULTS A brief, 5-minute cardiovascular limited ultrasound exam (CLUE) was taught using both didactic and bedside methods, and practiced primarily within the cardiology consult, outpatient clinic, and intensive care rotations. Program costs were minimized by employing readily available institutional resources. After a 2-year lead-in training phase, the subsequent 4 years of senior resident performance (n = 41 residents) showed an 81% pass rate in CLUE competency. Resident ultrasound performance did not relate to academic scores (r = 0.05, P = 0.75), chief resident selection, nor gender. Observations regarding resident pitfalls in CLUE practice and increased participation in extracurricular research are described. CONCLUSIONS We report our initial experience in developing and implementing a training program for bedside cardiovascular ultrasound examination that employed evidence-based techniques, set proficiency goals, and assessed resident performance. It may be feasible to teach future internist-hospitalists the technique of bedside ultrasound during residency.

A bedside ultrasound sign of cardiac disease: the left atrium-to-aorta diastolic diameter ratio

PURPOSE This study evaluated a simple ultrasound method to detect left atrial (LA) enlargement by comparing the diameters of the LA and aortic root. PROCEDURES The LA and aortic diameters, the LA volume index (LAVI), and significant echo findings were analyzed in 101 consecutive echocardiograms. Mean LAVI and the prevalence of an abnormal echo were compared between groups in which the ratio of the LA diameter to aortic diameter in diastole was >1 vs < or = 1. FINDINGS Left atrial-to-aortic diameter ratio increased with LAVI (r = 0.64, P < .001). Left atrial-to-aortic diameter ratio >1 vs < or = 1 was noted in 45% vs 55% of patients and had a mean (+ or - SD) LAVI = 39 + or - 12 vs 27 + or - 7 mL/m(2) (P < .001) and a 78% vs 43% prevalence of an abnormal echo (P < .001). CONCLUSION The left atrium-to-aorta diastolic diameter ratio can detect LA enlargement and may be useful as a quick bedside technique to screen for cardiac disease.

Effect of Morbidity and Mortality Peer Review on Nurse Accountability and Ventilator-Associated Pneumonia Rates

Objective: This program was designed to evaluate the effect of morbidity and mortality peer review conferences (MMPRCs) for ventilator-associated pneumonia (VAP) on nurse accountability and compliance with evidence-based VAP prevention practices. Background: Ventilator-associated pneumonia is associated with longer average length of stay (ALOS), greater cost, and increased morbidity and mortality. Traditionally, passive or punitive methods have been used to reduce undesirable outcomes. The MMPRC is not a conventional nursing intervention. Methods: Each MMPRC included case history, relevant hospital course, diagnostic comorbidities, and compliance with VAP prevention strategies. The preventability of each VAP was determined by RN peers. Ventilator days, VAP bundle compliance, VAP incidence, ICU ALOS, cost, and satisfaction data were collected. Results: Nurse accountability improved significantly (χ2 = 24.041, P < .001), and VAP incidence was reduced. Data demonstrated satisfaction with the MMPRC. Number of ventilator days and ALOS did not change significantly, although VAP bundle compliance improved from 90.1% to 95.2%. Conclusions: The nonpunitive MMPRC process was cost-effective and should be considered for other nurse-sensitive indicators to increase nurse accountability and improve outcomes.

Feasibility of remote real-time guidance of a cardiac examination performed by novices using a pocket-sized ultrasound device.

Background. The potential of pocket-sized ultrasound devices (PUDs) to improve global healthcare delivery is limited by the lack of a suitable imaging protocol and trained users. Therefore, we investigated the feasibility of performing a brief, evidence-based cardiac limited ultrasound exam (CLUE) through wireless guidance of novice users. Methods. Three trainees applied PUDs on 27 subjects while directed by an off-site cardiologist to obtain a CLUE to screen for LV systolic dysfunction (LVSD), LA enlargement (LAE), ultrasound lung comets (ULC+), and elevated CVP (eCVP). Real-time remote audiovisual guidance and interpretation by the cardiologist were performed using the iPhone 4/iPod (FaceTime, Apple, Inc.) attached to the PUD and transmitted data wirelessly. Accuracy and technical quality of transmitted images were compared to on-site, gold-standard echo thresholds. Results. Novice versus sonographer imaging yielded technically adequate views in 122/135 (90%) versus 130/135 (96%) (P < 0.05). CLUEs combined SN, SP, and ACC were 0.67, 0.96, and 0.90. Technical adequacy (%) and accuracy for each abnormality (n) were LVSD (85%, 0.93, n = 5), LAE (89%, 0.74, n = 16), ULC+ (100%, 0.94, n = 5), and eCVP (78%, 0.91, n = 1). Conclusion. A novice can perform the CLUE using PUD when wirelessly guided by an expert. This method could facilitate PUD use for off-site bedside medical decision making and triaging of patients.

Workplace Blame and Related Concepts: An Analysis of Three Case Studies

Blame has been thought to affect quality by decreasing error reporting. Very little is known about the incidence, characteristics, or consequences of the distress caused by being blamed. Blame-related distress (B-RD) may be related to moral distress, but may also be a factor in burnout, compassion fatigue, lateral violence, and second-victim syndrome. The purpose of this article is to explore these related concepts through a literature review applied to three index critical care clinician cases.

Exploring Distress Caused by Blame for a Negative Patient Outcome.

OBJECTIVE: The aim of this study was to explore blame-related distress (B-RD). BACKGROUND: No research exists describing the incidence and characteristics of consequences of blame. METHODS: Survey research was used to explore the incidence, characteristics, and consequences of the distress caused by blame in the workplace. RESULTS: B-RD is prevalent among intensive care and oncology staff. Participants reported an organizational impact to B-RD in terms of staff morale, turnover, and employee health. Management, physicians, and peers were the most frequently cited source of blame. CONCLUSIONS: A proposed model is described to relate blame to other similar constructs.

Beat-to-beat corrected QT analysis detects corrected QT prolongation in 50 consecutive telemetry-monitored patients.

Background:The American Heart Association/American College of Cardiology Foundation recommends monitoring for corrected QT (QTc) prolongation. The incidence of QTc prolongation in the general public is unknown. Episodic measurements may miss patients at risk. Objective:The purpose of this study was to determine the incidence of QTc prolongation in hospitalized telemetry patients when beat-to-beat monitoring, confirmed by manual calculation, was used for detection. Methods:After institutional review board approval was obtained, waveforms of telemetry-monitored patients were analyzed consecutively until 50 patients with prolonged QTc were identified (QTc >470 milliseconds in men and >480 milliseconds in women). Prolongation was confirmed by manual calculation. Incidence was calculated. Clinical risk factors and the outcomes of torsades de pointe or sudden death were explored. Results:Telemetry waveforms were evaluated for 192 444 minutes (3207.4 hours) of recordings, yielding 8 076 653 QTc measurements. In 50 consecutive patients (24 [48%] men), 100% had verified episode(s) of QTc prolongation. Home medications that could result in QTc prolongation were identified in 9 patients (18%). Hospital medications with risk of QTc prolongation were administered to 31 patients (62%). Sixteen patients (32%) were not on a QTc-prolonging medication. Corrected QT prolongation risk factors in the history were found in 2 patients (4%) and hypomagnesemia or hypokalemia was seen in 6 patients (12%). Twelve-lead electrocardiogram detected prolonged QTc in 13 of 45 patients (26%). Prolongation of QTc was detected by standard of care manual analysis in 4 patients (8%). No patient experienced torsades de pointe or sudden death. Conclusion:With beat-to-beat analysis, QTc prolongation was detected in 100% of 50 consecutive patients where standard of care (nursing manual analysis or 12-lead electrocardiogram) would have detected 28%. Hospital medications were more likely to contribute to QTc prolongation than home medications. Implications for Practice:More specific definitions for determining proarrhythmic risk are needed as automated technology improves the capture rate of QTc prolongation events.