Rodrigo F. Alban

Measuring Communication in the Surgical ICU: Better Communication Equals Better Care

BACKGROUND The Joint Commission on the Accreditation of Healthcare Organizations reports that communication breakdowns are responsible for 85% of sentinel events in hospitals. Patients in surgical ICUs are the most vulnerable to communication errors. Fellows and residents are an integral part of the surgical ICU team, but little is known about resident-fellow communication and its impact on surgical ICU patient outcomes. The objective of this study is to describe resident-fellow patient care communication patterns in the surgical ICU and correlate established communication patterns with short-term outcomes. STUDY DESIGN A prospective observational trial was conducted for 136 consecutive surgical ICU days. We evaluated resident-fellow communication of four cardiorespiratory events: hypotension, new arrhythmias, tachypnea, and desaturation. We prospectively defined three short-term outcomes: improved, not improved, and worse. An intervention was attempted to improve communication. RESULTS Three hundred twelve events were collected (166 observational and 146 interventional). PGY3 residents covered approximately 60% of days in both phases. PGY3 residents were responsible for 73% of communication errors in the observational phase and 59% of communication errors in the interventional phase. Communication errors were more likely in the late shift (p < 0.0001). The late shift was responsible for 77% of all communication errors. Communication errors resulted in worse short-term outcomes for cardiorespiratory events (p < 0.0002). Effective communication was a significant predictor of improved short-term outcomes (p < 0.0003). The intervention decreased communication errors in the late shift by 10% (p < 0.052). CONCLUSIONS Communication errors occurred more frequently during the late shift. These communication errors were associated with worsened short-term outcomes. Improved communication in the surgical ICU is a fruitful target to improve clinical outcomes.

Hypocalcemia in trauma patients receiving massive transfusion

BACKGROUND Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium is vital for coagulation, but hypocalcemia commonly occurs during massive transfusion due to citrate and serum calcium chelation. This study was conducted to determine the incidence of hypocalcemia and severe hypocalcemia in trauma patients who receive massive transfusion and to compare characteristics of patients with severe versus nonsevere hypocalcemia. MATERIALS AND METHODS This was a retrospective study of trauma patients who received massive transfusion between January 2009 and November 2013. The primary outcome was the incidence of hypocalcemia (ionized calcium [iCa] < 1.12 mmol/L) and severe hypocalcemia (iCa < 0.90 mmol/L). Secondary outcomes included calcium monitoring, calcium replacement, and correction of coagulopathy. RESULTS There were 156 patients included; 152 (97%) experienced hypocalcemia, and 111 (71%) had severe hypocalcemia. Patients were stratified into iCa ≥ 0.90 (n = 45) and iCa < 0.90 (n = 111). There were no differences in demographics or baseline laboratories except the severe hypocalcemia group had higher baseline activated partial thromboplastin time (29.7 [23.7-50.9] versus 25.8 [22.3-35.9], P = 0.003), higher lactic acid (5.8 [4.1-9.8] versus 4.0 [3.1-7.8], P = 0.019), lower platelets (176 [108-237] versus 208 [169-272], P = 0.003), and lower pH (7.14 [6.98-7.28] versus 7.23 [7.14-7.33], P = 0.019). Mortality was higher in the severe hypocalcemia group (49% versus 24%, P = 0.007). Patients in the iCa < 0.90 group received more blood products (34 [23-58] versus 22 [18-30] units, P < 0.001), and calcium chloride (4 [2-7] versus 3 [1-4] g, P = 0.002), but there was no difference in duration of MTP or final iCa. Neither group reached a median iCa > 1.12. CONCLUSIONS Hypocalcemia is common during MTP, and vigilant monitoring is warranted. Research is needed to effectively manage hypocalcemia during massive transfusion.

Improving Donor Conversion Rates at a Level One Trauma Center: Impact of Best Practice Guidelines

Background Organ availability is a consistently limiting factor in transplant surgery. A primary driver of this limitation is donor conversion rate, which is defined as the percentage of eligible donors for whom procurement is actually performed. An alternative way to increase organ availability is through improved utilization of organs from donors after cardiac death (DCD). Recently, a concerted, multidisciplinary effort has been made within our system to improve conversion rates and DCD utilization, thus increasing organ availability. Study design Retrospective analysis of a prospectively collected database from TransLife, our local organ procurement organization (OPO), as well as the Orlando Regional Medical Center (ORMC) trauma registry, from 2009-2012 (up to 2013 for DCD). During which time, this organization implemented best practice guidelines to improve conversions and DCD utilization. We analyzed yearly conversion rates, DCD donations and population demographics before and after implementation of these policies. Results During the study period, donor conversion rates significantly improved from 58% in 2009 to 82% percent in 2012 hospital-wide (P<0.05); and from 50% in 2009 to 81% in 2012 among trauma patients alone (P<0.05). In addition, total organs transplanted increased from 13 to 31 organs (P<0.05) after implementation of best practice guidelines. No significant differences in trauma population demographics were noted during the study period. Conclusions Based on our experience, the establishment of best practice policies for referral of potential donors, coupled with programs to educate hospital staff on the existence and importance of these policies, leads to significant improvement in donor conversion rates and increased utilization of DCD donors.

831: Failure to Rescue After Rapid Response Team Activations in Surgical Patients

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) establishing inter-rater reliability. 12 Ideal Team Tasks were identified by a hospital quality improvement committee and event observations included tracking of compliance with these tasks (e.g. whether or not role clarity was established). Team performance was measured during each event using the Team Emergency Assessment Measure tool (2010) with an additional overall global rating ranging from 0=worst to 10=best. Results: 31 RRT events were observed and the global rating was fair (average=6.58). The number of Ideal Team Tasks completed (average=6.58) was significantly positively correlated with global rating (p=0.03). Nurses activated the team in 45% of events, but the licensed independent practitioner presented the patient case in all events. The ICU fellow introduced themselves in 45.2% of cases and the team in only 9.68% of cases. A complete situation, background, assessment, and recommendation were presented by the primary team in 16% of events. The ICU fellow stated a robust plan in 63.2% of events, but asked the primary team if they had questions in only 22.6% of events. When parents were present, the ICU fellow explained the plan to them in 71.4% of cases. However, when parents were not present, the ICU fellow assigned someone to update the family in only 22.2% of cases. Conclusions: Our results demonstrate support for the use of the 12 Ideal Team Tasks in team training given the relationship between task completion and global rating. Improved performance through a training program based on these tasks and Crew Resource Management principles is currently being sought.

In-hospital fellow coverage reduces communication errors in the surgical intensive care unit☆

BACKGROUND Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events. METHODS A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods. RESULTS Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (P<.0001). Residents communicated 89% of events during IHFC vs 51% of events during HC (P<.001). Communication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, P<.001). Junior residents communicated 66% of events (94% IHFC vs 52% HC, P<.001). Communication errors were lower in all ICUs during IHFC (P<.001). CONCLUSIONS IHFC reduced communication errors.

1066: THE INCIDENCE OF HYPOCALCEMIA IN TRAUMA PATIENTS RECEIVING MASSIVE TRANSFUSION PROTOCOL

Learning Objectives: Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium (Ca) is vital to the coagulation pathway, but hypocalcemia (hypoCa) is common during MTP due to citrate and serum Ca binding. There is a paucity of data describing the incidence and clinical significance of hypoCa during MTP. This study was conducted to determine the incidence of hypoCa in trauma patients who receive MTP. We hypothesized that hypoCa is common during MTP and may perpetuate coagulopathy. Methods: This was a retrospective study of consecutive trauma patients who received MTP between Jan 2009 and Dec 2013. Data was collected from admission through 24 hours after discontinuation of MTP or death. Patients were excluded for incomplete records and age <18 years. Demographics, injury severity score, fluid and blood product administration, ionized Ca (iCa), and Ca replacement were collected. HypoCa was defined as iCa <1.12 mmol/L and severe hypoCa as iCa <0.90 mmol/L. Results: A total of 172 MTP patients were identified and 156 included. Of these, 91(58%) survived and 65(42%) expired. There were no differences in demographics or baseline labs except non-survivors (Non-S) had higher PT (19.9 ± 17 vs. 13.2 ± 4, p<0.01) and aPTT (59.9 ± 40 vs. 33.6 ± 31, p<0.01), lower pH (7.09 ± 0.2 vs. 7.18 ± 0.2, p<0.01), and received more blood products (52 ± 41 vs. 34 ± 24 units, p<0.01). There was no difference in fluid administered between groups. HypoCa occurred in 90(99%) survivors (S) and 62(95%) Non-S (p=0.3). Severe hypoCa occurred more frequently in Non-S vs. S [54(83%) vs. 57(63%), p<0.01]. Non-S received more total Ca replacement (5.4 ± 4.4 vs. 3.9 ± 3.3 gm, p=0.01) and were more likely to have uncorrected coagulopathy at the end of MTP (18.5% vs. 1.1%, p<0.01). Multivariate logistic regression was performed using baseline PT, aPTT, pH, temperature, total blood units and severe hypoCa to predict failure of coagulopathy reversal. Only temperature and aPTT were significant predictors (p=0.04, p=0.03, respectively). Conclusions: HypoCa is common during MTP, but severe hypoCa was not a predictor of coagulopathy reversal.