Hildy Schell-Chaple

Preventing Harm in the Icu—building a Culture of Safety and Engaging Patients and Families

Objective: Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts. Data Sources: Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched. Study Selection: Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations. Data Extraction: Our group determined by consensus which resources would best inform this review. Data Synthesis: A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded. Conclusions: Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.

Effects of Iv Acetaminophen on Core Body Temperature and Hemodynamic Responses in Febrile Critically Ill Adults: A Randomized Controlled Trial.

Objective: To determine the effects of IV acetaminophen on core body temperature, blood pressure, and heart rate in febrile critically ill patients. Design: Randomized, double-blind, placebo-controlled clinical trial. Setting: Three adult ICUs at a large, urban, academic medical center. Patients: Forty critically ill adults with fever (core temperature, ≥ 38.3°C). Intervention: An infusion of acetaminophen 1 g or saline placebo over 15 minutes. Measurement and Main Results: Core temperature and vital signs were measured at baseline and at 5–15-minute intervals for 4 hours after infusion of study drug. The primary outcome was time-weighted average core temperature adjusted for baseline temperature. Secondary outcomes included adjusted time-weighted average heart rate, blood pressure, and respiratory rate, along with changes-over-time for each. Baseline patient characteristics were similar in those given acetaminophen and placebo. Patients given acetaminophen had an adjusted time-weighted average temperature that was 0.47°C less than those given placebo (95% CI, –0.76 to –0.18; p = 0.002). The acetaminophen group had significantly lower adjusted time-weighted average systolic blood pressure (–17 mm Hg; 95% CI, –25 to –8; p < 0.001), mean arterial pressure (–7 mm Hg; 95% CI, –12 to –1; p = 0.02), and heart rate (–6 beats/min; 95% CI, –10 to –1; p = 0.03). Changes-over-time temperature, blood pressure, and heart rate outcomes were also significantly lower at 2 hours, but not at 4 hours. Conclusions: Among febrile critically ill adults, treatment with acetaminophen decreased temperature, blood pressure, and heart rate. IV acetaminophen thus produces modest fever reduction in critical care patients, along with clinically important reductions in blood pressure.

Measuring patient respect in the intensive care unit: Validation of the ICU-RESPECT instrument

Purpose: To validate a brief index of patient and family experiences of respect in the intensive care unit. Material and methods: A survey including the 10‐item ICU‐RESPECT scale was administered to patients and family members in one ICU at a large west coast academic medical center. Confirmatory psychometric analyses were conducted. Results: Based on 142 completed surveys, factor analysis confirmed a unidimensional scale with an alpha of 0.90, an Eigen value of 4.9, and factor loadings from 0.50 to 0.86. The mean total score was 7.59 (SD = 3.06) out of a maximum of 10. Among the 106 surveys that included demographics, overall scores did not differ by type of respondent (patient or family) or by gender. There were modest differences in overall scores by patient race. Two individual items differed by type of respondent. Conclusions: The ICU‐RESPECT index demonstrates reliability and concurrent validity in a different ICU setting from the one where the index was developed. Future research should assess the scales predictive validity, and factors associated with variation in scores. As hospitals address patient experience more broadly in response to national metrics, the index could identify particular behaviors or ICUs that would benefit from interventions to enhance respectful treatment. HIGHLIGHTSThe psychometric properties of the 10‐item self‐reported “ICU‐RESPECT” index were confirmed in a second ICU setting.The ICU‐RESPECT index is unidimensional with an alpha of 0.90, an Eigen value of 4.9, and a mean total score of 7.59 out of 10.The “ICU‐RESPECT” index can be used to develop and evaluate educational interventions to counteract disrespectful treatment of patients and families in the ICU.

Intensive care unit providers more quickly and accurately assess risk of multiple harms using an engineered safety display

Project Emerge took a systems engineering approach to reduce avoidable harm in the intensive care unit. We developed a socio-technology solution to aggregate and display information relevant to preventable patient harm. We compared providers’ efficiency and ability to assess and assimilate data associated with patient-safety practice compliance using the existing electronic health record to Emerge, and evaluated for speed, accuracy, and the number of mouse clicks required. When compared to the standard electronic health record, clinicians were faster (529 ± 210 s vs 1132 ± 344 s), required fewer mouse clicks (42.3 ± 15.3 vs 101.3 ± 33.9), and were more accurate (24.8 ± 2.7 of 28 correct vs 21.2 ± 2.9 of 28 correct) when using Emerge. All results were statistically significant at a p-value < 0.05 using Wilcoxon signed-rank test (n = 18). Emerge has the potential to make clinicians more productive and patients safer by reducing the time and errors when obtaining information to reduce preventable harm.

Rectal and Bladder Temperatures vs Forehead Core Temperatures Measured With SpotOn Monitoring System

Background Methods and frequency of temperature monitoring in intensive care unit patients vary widely. The recently available SpotOn system uses zero‐heat‐flux technology and offers a noninvasive method for continuous monitoring of core temperature of critical care patients at risk for alterations in body temperature. Objective To evaluate agreement between and precision of a zero‐heat‐flux thermometry system (SpotOn) and continuous rectal and urinary bladder thermometry during fever and defervescence in adult patients in intensive care units. Methods Prospective comparison of SpotOn vs rectal and urinary bladder thermometry in eligible patients enrolled in a randomized clinical trial on the effect of acetaminophen on core body temperature and hemodynamic status. Results A total of 748 paired temperature measurements from 38 patients who had both SpotOn monitoring and either continuous rectal or continuous bladder thermometry were analyzed. Temperatures during the study were from 36.6°C to 39.9°C. The mean difference for SpotOn compared with bladder thermometry was ‐0.07°C (SD, 0.24°C; 95% limits of agreement, ± 0.47°C [‐0.54°C, 0.40°C]). The mean difference for SpotOn compared with rectal thermometry was ‐0.24°C (SD, 0.29°C; 95% limits of agreement, ± 0.57°C [‐0.81°C, 0.33°C]). Most differences in temperature between methods were within ± 0.5°C in both groups (96% bladder and 85% rectal). Conclusions The SpotOn thermometry system has excellent agreement and good precision and is a potential alternative for noninvasive continuous monitoring of core temperature in critical care patients, especially when alternative methods are contraindicated or not available.

Continuous Renal Replacement Therapies: Raising the Bar for Quality Care

C renal replacement therapy (CRRT) has become a standard therapy option and has been widely used for critically ill patients requiring renal support since it was introduced 4 decades ago.1-4 Patients requiring CRRT are typically at high risk of death related to their severity of illness, and mortality rates in this population have remained steady around 50% since the advent of CRRT.5-8 The advances in CRRT hemofilter supplies and device technologies in the past 2 decades aimed to improve safety and quality in delivery of this therapy. Despite these improvements, the variability in CRRT practice has been implicated as a potential contributing factor in morbidity and mortality outcomes for patients receiving this therapy.9,10 Patients who require CRRT are especially vulnerable for poor outcomes because of the severity of their critical illness, which potentially limits their resiliency to standard practice breaches and related complications.9 This symposium is intended to increase awareness and knowledge of best-practice strategies for safe and high-quality CRRT care that improve patients’ outcomes. The articles in this symposium present a review of best-practice quality recommendations for CRRT, including recommendations from a recent expert consensus conference,11 a model for CRRT training and competency evaluation that expands beyond initial orientation, an overview of considerations for medication management during CRRT, and a series of 3 case vignettes that highlight different applications of CRRT that are based on patient-specific goals of therapy.

Continuous Renal Replacement Therapy Update: An Emphasis on Safe and High-Quality Care

&NA; Continuous renal replacement therapy (CRRT) was introduced more than 40 years ago as a renal support option for critically ill patients who had contraindications to intermittent hemodialysis and peritoneal dialysis. Despite being the most common renal support therapy used in intensive care units today, the tremendous variability in CRRT management challenges the interpretation of findings from CRRT outcome studies. The lack of standardization in practice and training of clinicians along with the high risk of CRRT‐related adverse events has been the impetus for the recent expert consensus work on identifying quality indicators for CRRT programs. This article summarizes the potential complications that establish CRRT as a high‐risk therapy and also the recently published best‐practice recommendations for providing high‐quality CRRT.

1198: TARGET RASS: AN EXAMPLE OF LEVERAGING THE EHR TO STANDARDIZE GOAL-BASED INTERVENTIONS.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) variability in rates prompted us to evaluate the sustainability of CLABSI reduction efforts and maintenance of evidence-based practices in Michigan ICUs. Methods: We conducted a gap analysis using a web-based survey of our participating ICUs. A survey link was sent to 100 Infection Preventionists whose hospital provides ICU care. Survey questions queried if evidence-based practices that were introduced in 2003 (e.g. insertion bundle checklist, hand hygiene, dedicated central line team and stop-the-line culture) are still utilized during central line placement. Results: Eighty hospitals submitted a completed gap analysis between January and mid-March 2016, an 80% response rate. Nearly all hospitals indicated continued use of an insertion bundle (96.5%) with 90% utilizing an insertion checklist. Further, 98.75% of respondents indicated applying full maximum barrier precautions during insertion. Hand hygiene protocols are in place at 98.75% of ICUs and enforced 88.9% of the time. Eighty percent report stop-the-line culture for an observed aseptic violation and 90% avoid a femoral insertion site. Central lines are discussed during rounds in 90% of the sample. Only 26%t report dedicated central line teams. Maintenance of central lines was identified as the primary concern of preventing CLABSI at 75% vs. insertion or removal. Conclusions: Michigan ICUs have maintained evidence-based central-line insertion practices and continued efforts to prevent CLABSI. Dedicated central-line teams and maintenance of central-lines represent the greatest opportunity for continued quality improvement efforts. Michigan ICUs continue to exhibit a high rate of compliance with CLABSI reduction interventions more than 10 years after conclusion of the initial grant funding.

893: TEMPERATURE AND HEMODYNAMIC RESPONSE TO ACETAMINOPHEN IN FEBRILE ICU PATIENTS: A RANDOMIZED TRIAL.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) common in the clinical setting, there is little in vivo data to support this practice. Critically ill patients are especially susceptible to changes in potassium due to their complex state. The objective of this study was to determine the average change in serum potassium following intravenous KCl administration and whether baseline renal function and concomitant medications affect levels. Methods: A retrospective chart review of 150 patients admitted to the medical/surgical intensive care unit between January 1, 2015 and June 30, 2015. Demographics, potassium and magnesium levels, serum creatinine, potassium administered, and other medications administered were collected from the chart. Linear mixed models examined the relationship between amount of KCl received and change in potassium level. The average change in potassium for every 10 mEq of KCl received was determined. Secondary outcomes included change in potassium based on renal function and the administration of other medications. Results: 265 total patients were evaluated for the study. The average change in potassium was 0.08 mmol/L for every 10 mEq of KCL received (P < 0.0001). The average change in potassium for every 10 mEq of potassium was 0.27 mmol/L in the presence of succinylcholine (P = 0.0343) and – 0.129 mmol/L in the presence of diuretics (P = 0.0238). The average change in potassium per 10 mEq of KCl received was 0.116 mmol/L for a CrCl < 30 mL/min (P = 0.0238), 0.069 mmol/L for a CrCl of 31 – 59 mL/min (P =0.0033), 0.042 mmol/L for a CrCl of 60 – 89 mL/min (P = 0.32), and 0.1061 mmol/L for a CrCl of > 90 mL/min (P < 0.0001). Conclusions: In critically ill patients, the average change in serum potassium was 0.08 mmol/L for every 10 mEq of KCl administered. When replacing potassium in the critically ill patient, it is important to consider baseline renal function as well as concomitant medication use.

QRS Amplitude Variation During Monitoring

©2016 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2016791 Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Salah S. Al-Zaiti is an assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Teri M. Kozik is a nurse researcher at St. Joseph’s Medical Center, Stockton, California. Hildy Schell-Chaple is a clinical nurse specialist and Michele M. Pelter is an assistant professor at the the Department of Physiological Nursing at University of California, San Francisco, California. ECG Puzzler