Liza Weavind

Workflow in intensive care unit remote monitoring: A time-and-motion study.

Objective:To investigate workflow in intensive care unit remote monitoring, a technology-driven practice that allows critical care specialists to perform proactive and continuous patient care from a remote site. Design:A time-and-motion study. Setting:Facility that remotely monitored 132 beds in nine intensive care units. Participants:Six physicians and seven registered nurses. Interventions:Participants were observed for 47 and 39 hrs, respectively. Measurements and Main Results:Clinicians’ workflow was analyzed as goal-oriented tasks and activities. Major variables of interest included the times spent on different types of tasks and activities, the frequencies of accessing various information resources, and the occurrence and management of interruptions in workflow. Physicians spent 70%, 3%, 3%, and 24% of their time on patient monitoring, collaboration, system maintenance, and administrative/social/personal tasks, respectively. For nurses, the time allocations were 46%, 3%, 4%, and 17%, respectively. Nurses spent another 30% of their time maintaining health records. In monitoring patients, physicians spent more percentage times communicating with others than the nurses (13% vs. 7%, p = .026) and accessed the in-unit clinical information system more frequently (42 vs. 14 times per hour, p = .027), while nurses spent more percentage times monitoring real-time vitals (16% vs. 2%, p = .012). Physicians’ and nurses’ workflows were interrupted at a rate of 2.2 and 7.5 times per hour (p < .001), with an average duration of 101 and 45 secs, respectively (p = .006). The sources of interruptions were significantly different for physicians and nurses (p < .001). Conclusions:Physicians’ and nurses’ task performance and information utilization reflect the distributed nature of work organization in intensive care unit remote monitoring. Workflow interruption, clinical information system usability, and collaboration with bedside caregivers are the major issues that may affect the quality and efficiency of clinicians’ work in this particular critical care setting.

A Model-Integrated, Guideline-Driven, Clinical Decision-Support System

Using evidence-based guidelines to standardize the care of patients with complex medical problems is a difficult challenge. In acute care settings, such as intensive care units, the inherent problems of stabilizing and improving vital patient parameters is complicated by the division of responsibilities among different healthcare team members. Computerized support for implementing such guidelines has tremendous potential. The use of model-integrated techniques for specifying and implementing guidelines as coordinated asynchronous processes is a promising new methodology for providing advanced clinical decision support. Combined with visual dashboards, which show the status of the implemented guidelines, a new approach to computer-supported care is possible. The Vanderbilt Medical Center is applying these techniques to the management of sepsis.

Balanced Crystalloids versus Saline in Critically Ill Adults

BACKGROUND Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU). METHODS We conducted a single‐center, pragmatic, multiple‐crossover trial comparing balanced crystalloids (lactated Ringers solution or Plasma‐Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16‐month trial. The primary outcome was hospital‐free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days — a composite of death from any cause, new renal‐replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) — all censored at hospital discharge or 30 days, whichever occurred first. RESULTS A total of 13,347 patients were enrolled, with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned crystalloid. The number of hospital‐free days did not differ between the balanced‐crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced crystalloids, 0.98; 95% confidence interval [CI], 0.92 to 1.04; P=0.41). Balanced crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P=0.01). CONCLUSIONS Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital‐free days between treatment with balanced crystalloids and treatment with saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SALT‐ED ClinicalTrials.gov number, NCT02614040.)

An Electronic Tool for the Evaluation and Treatment of Sepsis in the ICU: A Randomized Controlled Trial.

Objectives:To determine whether addition of an electronic sepsis evaluation and management tool to electronic sepsis alerting improves compliance with treatment guidelines and clinical outcomes in septic ICU patients. Design:A pragmatic randomized trial. Setting:Medical and surgical ICUs of an academic, tertiary care medical center. Patients:Four hundred and seven patients admitted during a 4-month period to the medical or surgical ICU with a diagnosis of sepsis established at the time of admission or in response to an electronic sepsis alert. Interventions:Patients were randomized to usual care or the availability of an electronic tool capable of importing, synthesizing, and displaying sepsis-related data from the medical record, using logic rules to offer individualized evaluations of sepsis severity and response to therapy, informing users about evidence-based guidelines, and facilitating rapid order entry. Measurements and Main Results:There was no difference between the electronic tool (218 patients) and usual care (189 patients) with regard to the primary outcome of time to completion of all indicated Surviving Sepsis Campaign 6-hour Sepsis Resuscitation Bundle elements (hazard ratio, 1.98; 95% CI, 0.75–5.20; p = 0.159) or time to completion of each element individually. ICU mortality, ICU-free days, and ventilator-free days did not differ between intervention and control. Providers used the tool to enter orders in only 28% of available cases. Conclusions:A comprehensive electronic sepsis evaluation and management tool is feasible and safe but did not influence guideline compliance or clinical outcomes, perhaps due to low utilization.

The Science and Economics of Improving Clinical Communication

This article presents a complex clinical scenario based on actual communication breakdowns that led to a sentinel event. Basic communication theory that underlies clinical interactions and the tenets of health care economic evaluation are reviewed. The process of the handoff as it relates to clinical interactions is discussed and the weaknesses in communication arising from handoff failures in the operative and critical care environments are examined. The discussion follows by looking at the influences of current medical culture, emerging technology, and changing care environments and their impact on communication behaviors and resultant effect on patient outcomes. A detailed cost analysis of the charges incurred for both standard and escalated care required for the case is followed by a discussion of the economic basis for improving clinical communication and patient safety using the SBAR tool.

Effect of anaesthesia type on postoperative mortality and morbidities: a matched analysis of the NSQIP database

Background. The anaesthetic technique may influence clinical outcomes, but inherent confounding and small effect sizes makes this challenging to study. We hypothesized that regional anaesthesia (RA) is associated with higher survival and fewer postoperative organ dysfunctions when compared with general anaesthesia (GA). Methods. We matched surgical procedures and type of anaesthesia using the US National Surgical Quality Improvement database, in which 264,421 received GA and 64,119 received RA. Procedures were matched according to Current Procedural Terminology (CPT) and ASA physical status classification. Our primary outcome was 30-day postoperative mortality and secondary outcomes were hospital length of stay, and postoperative organ system dysfunction. After matching, multiple regression analysis was used to examine associations between anaesthetic type and outcomes, adjusting for covariates. Results. After matching and adjusting for covariates, type of anaesthesia did not significantly impact 30-day mortality. RA was significantly associated with increased likelihood of early discharge (HR 1.09; P< 0.001), 47% lower odds of intraoperative complications, and 24% lower odds of respiratory complications. RA was also associated with 16% lower odds of developing deep vein thrombosis and 15% lower odds of developing any one postoperative complication (OR 0.85; P < 0.001). There was no evidence of an effect of anaesthesia technique on postoperative MI, stroke, renal complications, pulmonary embolism or peripheral nerve injury. Conclusions. After adjusting for clinical and patient characteristic confounders, RA was associated with significantly lower odds of several postoperative complications, decreased hospital length of stay, but not mortality when compared with GA.

Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital

Physician-led perioperative surgical home models are developing as a method for improving the American health care system. These models are novel, team-based approaches that help to provide continuity of care throughout the perioperative period. Another avenue for improving care for surgical patients is the use of enhanced recovery after surgery pathways. These are well-described methods that have shown to improve perioperative outcomes. An established perioperative surgical home model can help implementation, efficiency, and adherence to enhanced recovery after surgery pathways. For these reasons, the Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center created an Anesthesiology Perioperative Care Service that provides comprehensive care to surgical patients from their preoperative period through the continuum of their hospital course and postdischarge follow-up. In this brief report, we describe the development, implementation, and preliminary outcomes of the service.

Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients

Objectives: To determine the association between hemoglobin levels and the daily risk of individual organ dysfunctions in critically ill patients. Design: Post hoc analysis of prospectively collected data. Setting: Vanderbilt University Medical Center and Saint Thomas Hospital Medical and Surgical ICUs. Patients: Medical and surgical ICU patients admitted with respiratory failure or shock. Interventions: Baseline demographic data, and detailed in-ICU and hospital data, including daily lowest hemoglobin, were collected up to hospital day 30. We assessed patients daily for brain dysfunction (delirium, using Confusion Assessment Method for ICU), for renal and respiratory dysfunction (using the ordinal renal and respiratory Sequential Organ Failure Assessment score), and for ICU mortality. Associations between the lowest hemoglobin on a given day and organ dysfunctions the following day were assessed using multivariable regressions, adjusting for age, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity index, Framingham Stroke Risk Profile, ICU day, ICU type, sepsis, and current organ dysfunction status. A sensitivity analysis further adjusted for daily transfusions and fluid balance in a subset of our patients. Measurements and Main Results: We enrolled 821 patients with a median (interquartile range) age of 61 (51–71) years, Acute Physiology and Chronic Health Evaluation II score of 25 (19–31), and hemoglobin level of 10.0 (9.0–11.1) g/dL. There was no evidence of an association between lowest daily hemoglobin and brain dysfunction (p = 0.69 for delirium), renal dysfunction (p = 0.30), or ICU mortality (p = 0.95). The lowest hemoglobin on a given day was significantly associated with the respiratory Sequential Organ Failure Assessment score the following day; for each increasing hemoglobin unit, the odds of worsened respiratory Sequential Organ Failure Assessment score the following day were decreased by 36% (OR, 0.64; 95% CI, 0.53–0.77; p < 0.001). The sensitivity analysis including daily transfusions and fluid balance (in a subset of 518 patients) did not qualitatively change any of these associations. Conclusions: In this study in ICU patients, lower hemoglobin was associated with a higher probability of worsening respiratory dysfunction scores the following day. There was no evidence of association between hemoglobin and brain or renal dysfunction, or ICU mortality. The possible differential effects of anemia on organ dysfunctions seen in this hypothesis-generating study will have to be studied in a larger prospective study before any alterations to present restrictive transfusion guidelines can be recommended.