Patricia Folcarelli

Sustained effectiveness of a primary-team-based rapid response system.

Objective:Laws and regulations require many hospitals to implement rapid-response systems. However, the optimal resource intensity for such systems is unknown. We sought to determine whether a rapid-response system that relied on a patient’s usual care providers, not a critical-care–trained rapid-response team, would improve patient outcomes. Design, Setting, and PatientsAn interrupted time-series analysis of over a 59-month period. Setting:Urban, academic hospital. Patients:One hundred seven-one thousand, three hundred forty-one consecutive adult admissions. Intervention:In the intervention period, patients were monitored for predefined, standardized, acute, vital-sign abnormalities or marked nursing concern. If these criteria were met, a team consisting of the patient’s existing care providers was assembled. Measurements and Main Results:The unadjusted risk of unexpected mortality was 72% lower (95% confidence interval 55%–83%) in the intervention period (absolute risk: 0.02% vs. 0.09%, p < .0001). The unadjusted in-hospital mortality rate was not significantly lower (1.9% vs. 2.1%, p = .07). After adjustment for age, gender, race, season of admission, case mix, Charlson Comorbidity Index, and intensive care unit bed capacity, the intervention period was associated with an 80% reduction (95% confidence interval 63%–89%, p < .0001) in the odds of unexpected death, but no significant change in overall mortality [odds ratio 0.91 (95% confidence interval 0.82–1.02), p = .09]. Analyses that also adjusted for secular time trends confirmed these findings (relative risk reduction for unexpected mortality at end of intervention period: 65%, p = .0001; for in-hospital mortality, relative risk reduction = 5%, p = .2). Conclusions:A primary-team–based implementation of a rapid response system was independently associated with reduced unexpected mortality. This system relied on the patient’s usual care providers, not an intensive care unit based rapid response team, and may offer a more cost-effective approach to rapid response systems, particularly for systems with limited intensivist availability.

Emotional harm from disrespect: the neglected preventable harm

Consider these actual patient experiences: Despite being simultaneously dreadful and familiar to healthcare professionals,1 cases like these are not systematically identified or addressed in hospital quality improvement programmes.2 As a result, we have no good way of preventing them and patients inevitably continue to suffer from these unnecessary emotional harms. These cases are examples of preventable harm that are deserving of formal capture, classification and action by the healthcare system. The 1999 Institute of Medicine (IOM) Report To Err is Human found that existing definitions and systems for preventing harm were inadequate and recommended urgent, decisive steps to raise ‘standards and expectations for improvements in safety’.3 Since then our ability to define, measure and prevent patient harm has improved substantially. For instance, in 1999, central line-associated bloodstream infections were considered unfortunate, but expected complications. Today they are commonly prevented, saving many lives.4 To date, the patient safety movement has focused primarily on physical injury, but definitions of harm in healthcare are much broader:5 any ‘outcome that negatively affects the patients health and/or quality of life’.6 When asked about consequences of adverse events, patients emphasise emotional …

The Practice of Respect in the ICU

Abstract Although “respect” and “dignity” are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating “failures of respect” as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.

DEVELOPING PATIENT AND FAMILY EDUCATION SERVICES : INNOVATIONS FOR THE CHANGING HEALTHCARE ENVIRONMENT

As the healthcare environment changes, systems that have served hospitals well for many years no longer meet the current needs of patients, families, and communities. This is particularly true with regard to health education. The authors describe an innovative learning center that offers comprehensive health education services and programs designed to empower consumers with the information and skills needed to maintain health or recover from illness or injury.

Strategies for Preventing Wrong Site, Wrong Procedure, Wrong Patient Surgery

Note from column coordinator Charlotte Guglielmi: It is my pleasure to introduce a new column for our journal. I have heard time and time again that nurses need to better understand the different perspectives that each member of the surgical team brings to the table on topics that affect the care we deliver to our patients. We know that teamwork and effective communication enhance the safe care of patients. This column will provide a venue for colleagues from multiple disciplines to share opinions and commentary on some of the most critical clinical issues that face all of us. As each topic is identified, a critical question will be posed to the authors who will respond from their perspective. Linda Groah, AORN executive director and chief executive officer, will conclude each discussion with a summary of AORN’s response to the issue. I am

Ocular Pneumoplethysmography (OPG-Gee) in Noninvasive Evaluation of Carotid Artery Stenosis

Carotid artery stenosis can be evaluated noninvasively by ocular pneumo plethysmography (OPG-Gee). This simultaneously measures both ophthalmic artery pressures and is therefore capable of detecting pressure-reducing or hemodynamically significant carotid lesions. An OPG-angiography correlation was made for 200 carotid arteries in 110 patients. Sensitivity, specificity and overall accuracy were 91%, 89%, and 90% respectively, if calculated per artery. On a per patient basis these figures were 94%, 88%, and 91%. Applica tions of this rapid and simple technique in clinical practice include selection of patients for angiography and carotid endarterectomy, as well as early and late control of the operative results.

Failures in the Respectful Care of Critically Ill Patients

BACKGROUND The emotional toll of critical illness on patients and their families can be profound and is emerging as an important target for value improvement. One source of emotional harm to patients and families may be care perceived as inadequately respectful. The prevalence and risk factors for types of emotional harms is under-studied. METHODS This prospective cohort study was conducted in nine ICUs at a tertiary care academic medical center in the United States. Prevalence of inadequate respect for (a) the patient and (b) the family, as well as prevalence of perceived lack of control over the care of their loved ones, was assessed by the Family Satisfaction with Care in the Intensive Care Unit instrument. The relationship between these outcomes with demographic and clinical covariates was assessed. Stratification by patient survivorship was performed in sensitivity analysis. RESULTS Of more than 1,500 respondents, 16.9% and 21.8% reported that the patient or the family member, respectively, received inadequate respect. No clinical characteristics of the patients were associated with inadequate respect for either the patient or the family member. By comparison, more than half of respondents reported a lack of control over their loved ones care; this finding was associated with multiple clinical factors. Prevalence and associated factors differed by patient survivorship status. CONCLUSION Care that is inadequately respectful to patients and families in the setting of critical illness is prevalent but does not appear to be associated with clinical characteristics. The incidence of such emotional harms is nuanced, difficult to predict, and deserves further investigation.

Surveying Care Teams after in-Hospital Deaths to Identify Preventable Harm and Opportunities to Improve Advance Care Planning

BACKGROUND Reviewing in-hospital deaths is one way of learning how to improve the quality and safety of care. Postdeath surveys sent to the care team for patients who died may have a role in identifying opportunities for improvement. As part of a quality improvement initiative, a postdeath care team survey was developed to explore how it might augment the existing process for learning from deaths. METHODS A survey was sent to the care team for all inpatient deaths on the hospital medicine and medical ICU services at one institution. Survey responses were reviewed to identify cases that required further investigation. An iterative process of inductive coding was used to create a coding taxonomy to classify survey response free-text comments. RESULTS During the distribution period (September 25, 2015-December 28, 2015), 82 patients died, and 191 care team members were surveyed. Responses (138; 72.3% response rate) were collected through January 28, 2016. Based on the survey responses, 5 patients (6.1%) not identified by other review processes were investigated further, resulting in the identification of several important opportunities for improvement. The free-text comment analysis revealed themes around the importance of advance care planning in seriously ill patients, as well as evidence of the emotional and psychological strain on clinicians who care for patients who die. CONCLUSION Postdeath care team surveys can augment mortality review processes to improve the way hospitals learn from deaths. Free-text comments on such surveys provide information not otherwise identified during traditional mortality review processes, including the importance of advance care planning and the strain on clinicians whose patients die.