Mark Romig

Perceived benefit of a telemedicine consultative service in a highly staffed intensive care unit.

PURPOSE The aim of this study was to evaluate whether a nocturnal telemedicine service improves culture, staff satisfaction, and perceptions of quality of care in a highly staffed university critical care system. METHODS We conducted an experiment to determine the effect of telemedicine on nursing-staff satisfaction and perceptions of the quality of care in an intensive care unit (ICU). We surveyed ICU nurses using a modified version of a previously validated tool before deployment and after a 2-month experimental program of tele-ICU. Nurses in another, similar ICU within the same hospital academic medical center served as concurrent controls for the survey responses. RESULTS Survey responses were measured using a 5-point Likert scale, and results were analyzed using paired t testing. Survey responses of the nurses in the intervention ICU (n = 27) improved significantly after implementation of the tele-ICU program in the relations and communication subscale (2.99 ± 1.13 pre vs 3.27 ± 1.27 post, P < .01), the psychological working conditions and burnout subscale (3.10 ± 1.10 pre vs 3.23 ± 1.11 post, P < .02), and the education subscale (3.52 ± 0.84 pre vs 3.76 ± 0.78 post, P < .03). In contrast, responses in the control ICU (n = 11) declined in the patient care and perceived effectiveness (3.94 ± 0.80 pre vs 3.48 ± 0.86 post, P < .01) and the education (3.95 ± 0.39 pre vs 3.50 ± 0.80 post, P < .05) subscales. CONCLUSION Telemedicine has the potential to improve staff satisfaction and communication in highly staffed ICUs.

Enhancing the Quality of Care in the Intensive Care Unit : A Systems Engineering Approach

This article presents an overview of systems engineering and describes common core principles found in systems engineering methodologies. The Patient Care Program Acute Care Initiative collaboration between the Armstrong Institute of the Johns Hopkins School of Medicine and the Gordon and Betty Moore Foundation, which will use systems engineering to reduce patient harm in the intensive care unit, is introduced. Specific examples of applying a systems engineering approach to the Patient Care Program Acute Care Initiative are presented.

Effect of Accounting for Multiple Concurrent Catheters on Central Line-Associated Bloodstream Infection Rates: Practical Data Supporting a Theoretical Concern

BACKGROUND Central line-associated bloodstream infection (CLABSI) rates are gaining importance as they become publicly reported metrics and potential pay-for-performance indicators. However, the current conventional method by which they are calculated may be misleading and unfairly penalize high-acuity care settings, where patients often have multiple concurrent central venous catheters (CVCs). OBJECTIVE We compared the conventional method of calculating CLABSI rates, in which the number of catheter-days is used (1 patient with n catheters for 1 day has 1 catheter-day), with a new method that accounts for multiple concurrent catheters (1 patient with n catheters for 1 day has n catheter-days), to determine whether the difference appreciably changes the estimated CLABSI rate. DESIGN Cross-sectional survey. SETTING Academic, tertiary care hospital. PATIENTS Adult patients who were consecutively admitted from June 10 through July 9, 2009, to a cardiac-surgical intensive care unit and a surgical intensive and surgical intermediate care unit. RESULTS Using the conventional method, we counted 485 catheter-days throughout the study period, with a daily mean of 18.6 catheter-days (95% confidence interval, 17.2-20.0 catheter-days) in the 2 intensive care units. In contrast, the new method identified 745 catheter-days, with a daily mean of 27.5 catheter-days (95% confidence interval, 25.6-30.3) in the 2 intensive care units. The difference was statistically significant (P < .001). The new method that accounted for multiple concurrent CVCs resulted in a 53.6% increase in the number of catheter-days; this increased denominator decreases the calculated CLABSI rate by 36%. CONCLUSIONS The undercounting of catheter-days for patients with multiple concurrent CVCs that occurs when the conventional method of calculating CLABSI rates is used inflates the CLABSI rate for care settings that have a high CVC burden and may not adjust for underlying medical illness. Additional research is needed to validate and generalize our findings.

Developing a Comprehensive Model of Intensive Care Unit Processes: Concept of Operations.

Objectives This study aimed to use a systems engineering approach to improve performance and stakeholder engagement in the intensive care unit to reduce several different patient harms. Methods We developed a conceptual framework or concept of operations (ConOps) to analyze different types of harm that included 4 steps as follows: risk assessment, appropriate therapies, monitoring and feedback, as well as patient and family communications. This framework used a transdisciplinary approach to inventory the tasks and work flows required to eliminate 7 common types of harm experienced by patients in the intensive care unit. The inventory gathered both implicit and explicit information about how the system works or should work and converted the information into a detailed specification that clinicians could understand and use. Prototype ConOps to Eliminate Harm Using the ConOps document, we created highly detailed work flow models to reduce harm and offer an example of its application to deep venous thrombosis. In the deep venous thrombosis model, we identified tasks that were synergistic across different types of harm. We will use a system of systems approach to integrate the variety of subsystems and coordinate processes across multiple types of harm to reduce the duplication of tasks. Through this process, we expect to improve efficiency and demonstrate synergistic interactions that ultimately can be applied across the spectrum of potential patient harms and patient locations. Conclusions Engineering health care to be highly reliable will first require an understanding of the processes and work flows that comprise patient care. The ConOps strategy provided a framework for building complex systems to reduce patient harm.

Centralized Triage for Multiple Intensive care units: The central intensivist physician

Subspecialization of critical care units and overall increasing demand for critical care services has led to inefficiencies in allocation of critical care resources with potential impacts on hospital economics and patient outcomes. Centralized management of critical care resource allocation within an institution may improve use while simultaneously ensuring quality of patient care. The authors’ institution has implemented a Central Intensivist Physician (CIP) program to oversee resource allocation within the adult surgical intensive care units (ICUs). The result has been an improvement in patient flow throughout the surgical ICUs manifested by steady case cancellation rates despite increasing acuity and length of stay. Additionally, triage duties have been shifted from the individual unit physician to the CIP, resulting in improved provider satisfaction from improved continuity of rounds. The authors conclude that the CIP program may improve overall critical care resource use while maintaining unit specialization within a large tertiary care hospital setting.

Evaluation of Noninvasive Hemoglobin Monitoring in Surgical Critical Care Patients.

Objective:To assess the clinical utility of noninvasive hemoglobin monitoring based on pulse cooximetry in the ICU setting. Design and Setting:A total of 358 surgical patients from a large urban, academic hospital had the noninvasive hemoglobin monitoring pulse cooximeter placed at admission to the ICU. Core and stat laboratory hemoglobin measurements were taken at the discretion of the clinicians, who were blinded to noninvasive hemoglobin monitoring values. Measurement and Main Results:There was a poor correlation between the 2,465 time-matched noninvasive hemoglobin monitoring and laboratory hemoglobin measurements (r2 = 0.29). Bland-Altman analysis showed a positive bias of 1.0 g/dL and limits of agreement of –2.5 to 4.6 g/dL. Accuracy was best at laboratory values of 10.5–14.5 g/dL and least at laboratory values of 6.5–8 g/dL. At hemoglobin values that would ordinarily identify a patient as requiring a transfusion (< 8 g/dL), noninvasive hemoglobin monitoring consistently overestimated the patient’s true hemoglobin. When sequential laboratory values declined below 8 g/dL (n = 102) and 7 g/dL (n = 13), the sensitivity and specificity of noninvasive hemoglobin monitoring at identifying these events were 27% and 7%, respectively. At a threshold of 8 g/dL, continuous noninvasive hemoglobin monitoring values reached the threshold before the labs in 45 of 102 instances (44%) and at 7 g/dL, noninvasive hemoglobin monitoring did so in three of 13 instances (23%). Noninvasive hemoglobin monitoring minus laboratory hemoglobin differences showed an intraclass correlation coefficient of 0.47 within individual patients. Longer length of stay and higher All Patient Refined Diagnostic-Related Groups severity of illness were associated with poor noninvasive hemoglobin monitoring accuracy. Conclusions:Although noninvasive hemoglobin monitoring technology holds promise, it is not yet an acceptable substitute for laboratory hemoglobin measurements. Noninvasive hemoglobin monitoring performs most poorly in the lower hemoglobin ranges that include commonly used transfusion trigger thresholds and is not consistent within individual patients. Further refinement of the signal acquisition and analysis algorithms and clinical reevaluation are needed.

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.

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.

Intensivist Presence at Code Events Is Associated with High Survival and Increased Documentation Rates

To better support the highest function of the Johns Hopkins Hospital adult code and rapid response teams, a team leadership role was created for a faculty intensivist, with the intention to integrate improve processes of care delivery, documentation, and decision-making. This article examines process and outcomes associated with the introduction of this role. It demonstrates that an intensivist has the potential to improve patient care while offsetting costs through improved billing capture.

Data Driven Patient Safety and Clinical Information Technology

Healthcare information technology has improved the business of healthcare with mixed results for its impact on the delivery of care itself. As industry and regulatory pressures to improve the quality and safety of care through the reduction of preventable harms, it becomes imperative to align information systems to (a) collect real-time clinical data with patient care workflows and (b) provide quality and patient safety teams (and other stakeholders) easy access to meaningful process and outcomes data. To accomplish this, hospitals and other healthcare organizations must adopt emerging practices from the science of high reliability organizations (HROs). In addition, they must employ and adapt clinical IT systems to facilitate real-time collection, analysis and feedback of performance (on multiple levels) with data directly from care. An example, Project Emerge, from the Johns Hopkins Hospital, is presented.