Roy Ilan

Knowledge translation in critical care: Factors associated with prescription of commonly recommended best practices for critically ill patients*

Objective:To describe prescription rates of commonly recommended best practices (clinical interventions with a strong base of evidence supporting their implementation) for critically ill patients and determine factors associated with increased rates of prescription. Design:A retrospective observational study. Setting:A university-affiliated medical-surgical-trauma intensive care unit over a 1-yr period. Patients:One hundred randomly selected critically ill patients. Interventions:None. Measurements and Main Results:Among the best practices studied, there was great variability in the proportion of patients eligible (median 36.5%, range 10% to 100%) and the proportion without contraindication (32.5%, range 10% to 86%) for each practice. The median rate of prescription of best practices for eligible patients was 56.5%, with a range from 8% to 95%. There was greater prescription of best practices when standard admission orders included an option to prescribe them (p = .048). Among those practices with standard admission orders, there was greatest prescription for practices additionally having a specialty consultation service (p = .004). There was an inverse association between severity of illness and prescription of best practices (p = .001): Sicker patients were less likely to be prescribed best practices. Conclusions:There may be substantial variability in the acceptance and prescription of commonly recommended best practices for critically ill patients. Standard order sets and focused specialty consultation may improve knowledge translation and prescription of best practice.

Increasing patient safety event reporting in 2 intensive care units: A prospective interventional study

PURPOSE The aims of this study were to increase the reporting of patient safety events and to enhance report analysis and responsive action. MATERIALS AND METHODS A prospective, interventional study in 2 adult intensive care units (ICUs) in an academic center was used. A paper-based reporting system, adapted from a previously reported intervention, was introduced. A multifaceted approach, including education, reminders, regular updates, personal and group feedback, and weekly leadership rounds, was led by a patient safety committee. Committee members reviewed the reports and initiated solutions as required. RESULTS During the first year, a total of 332 safety events were reported using the new system, reflecting a significant increase in total reporting (10.3/1000 patient days preintervention to 34.5/1000 patient days postintervention; rate ratio, 3.35; 95% confidence interval, 2.23-5.04). Most reports were submitted by nurses (nurses, 75.3%; physicians, 10.5%; other workers, 7.8%). Overall reported events per 1000 patient days differed by unit (level 3 ICU, 44.1; level 2 ICU, 24.9; P < .001). Several system-based interventions were initiated in the ICUs to address reported safety hazards. CONCLUSIONS After the introduction of this new approach, reporting rates have increased significantly throughout the first year. Differences in reporting rates among workers and units may reveal priorities and barriers to reporting. The integrated approach facilitated prompt response to selected reports.

Coordinating Flexible Performance During Everyday Work: An Ethnomethodological Study of Handoff Routines

Our paper examines the challenge of coordinating flexible performance during everyday work. We draw on routine dynamics and ethnomethodology to examine how intensive care unit (ICU) physicians coordinate their actions—flexibly yet intelligibly—as they handoff patients at change of shift. Through our analysis of interview and video data, we demonstrate how physicians use the sequential features of the handoff routine—i.e., the expected moves and their expected sequence—to adapt each performance of the routine to the unique needs of each patient. We show the need for ongoing coordinating despite a strongly shared ostensive pattern and we illustrate how participants use the sequential nature of the ostensive pattern of the routine as a resource for flexible performance, to manage sequential variation and the sufficiency of moves at transitions. Our findings contribute to the routine dynamics and coordination literatures by providing a more nuanced understanding of how mutual intelligibility is achieved through coordinating, whereby participants create the conditions to move forward with a common project.

The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study

Background In the hospital setting, inadequate engagement between healthcare professionals and seriously ill patients and their families regarding end-of-life decisions is common. This problem may lead to medical orders for life-sustaining treatments that are inconsistent with patient preferences. The prevalence of this patient safety problem has not been previously described. Methods Using data from a multi-institutional audit, we quantified the mismatch between patients’ and family members’ expressed preferences for care and orders for life-sustaining treatments. We recruited seriously ill, elderly medical patients and/or their family members to participate in this audit. We considered it a medical error if a patient preferred not to be resuscitated and there were orders to undergo resuscitation (overtreatment), or if a patient preferred resuscitation (cardiopulmonary resuscitation, CPR) and there were orders not to be resuscitated (undertreatment). Results From 16 hospitals in Canada, 808 patients and 631 family members were included in this study. When comparing expressed preferences and documented orders for use of CPR, 37% of patients experienced a medical error. Very few patients (8, 2%) expressed a preference for CPR and had CPR withheld in their documented medical orders (Undertreatment). Of patients who preferred not to have CPR, 174 (35%) had orders to receive it (Overtreatment). There was considerable variability in overtreatment rates across sites (range: 14–82%). Patients who were frail were less likely to be overtreated; patients who did not have a participating family member were more likely to be overtreated. Conclusions Medical errors related to the use of life-sustaining treatments are very common in internal medicine wards. Many patients are at risk of receiving inappropriate end-of-life care.

Prolonged time to alarm in infusion devices operated at low flow rates.

Objective:To evaluate the time to occlusion alarm for peristaltic infusion devices used in Toronto adult critical care units. Design:Cross-sectional study. Setting:Biomedical engineering departments of four Toronto teaching hospitals. Subjects:Twenty peristaltic infusion devices (five Sigma 8000-plus, five Graseby 3000, five Baxter Colleague, and five Alaris 7230B). Interventions:None. Measurements:Time to occlusion alarm at flow rates of 2, 10, and 100 mL/hr at a full range of available pressure thresholds for occlusion detection, and with commonly used tubing sets. Main Results:At default (mid-range) pressure thresholds, mean (sd) time to occlusion alarm was 0.3 (0.1) min at a flow rate of 100 mL/hr, 2.3 (0.5) min at a flow rate of 10 mL/hr, and 11.7 (3.1) min at a flow rate of 2 mL/hr. Conclusions:Time to occlusion alarm in peristaltic infusion devices is long at low flow rates. Patients receiving important medications with short half-lives at low flow rates could experience clinically important interruptions in treatment. Time to occlusion alarm at high flow rates is short, which could lead to excessive alarms and “alarm mistrust” by clinical staff.

Creating patient safety capacity in a nation's health system: A comparison between Israel and Canada.

Injuries to patients by the healthcare system (i.e., adverse events) are common and their impact on individuals and systems is considerable. Over the last decade, extensive efforts have been made worldwide to improve patient safety. Given the complexity and extent of the activities required to address the issue, coordinating and organizing them at a national level is likely beneficial. Whereas some capacity and expertise already exist in Israel, there is a considerable gap that needs to be filled. In this paper two countries, Canada and Israel, are examined and some of the essential steps for any country are considered. Possible immediate next steps for Israel are suggested.

Multidisciplinary Approach to Critical Care Design: Information Sources and Utilization During Morning Rounds

The goal of this project is to improve clinical decision-making in the intensive care unit (ICU) environment. Making the optimal decisions depends on the quality and timeliness of the information available to the clinician. We believe that healthcare professionals will make better clinical decisions when the relevant information is collected and organized in a manner appropriate to support in situ decision-making. This is especially important in complex situations such those commonly encountered in the ICU environment. Currently there is no single integrated source of information that presents relevant information to clinicians. This project is developing methods to identify the core information required to engineer the information exchange among medical devices, and the information presentation layer, to support clinical decision-making in the ICU.

Engineering the Integrated Clinical Environment Organizing Information in the Intensive Care Unit (ICU)

The overarching goal of this project is to develop engineering requirements for future information resources in the ICU. We describe a method and related instrumentation for collecting data about information requirements from a clinical team in situ. Video records are collected using three consumer-grade video cameras, augmented by a wireless microphone system. We combine the video/audio recordings into a single, synchronized record. A transcript is prepared, and then coded by a professional medical records coder, using the SNOMED CT coding scheme. The resulting record represents a coded stream of verbal utterances that is sufficiently precise to support systems engineering analysis.

Information Display in the Intensive Care Unit – Considerations for System Design and Implementation

Healthcare working environments are complex, and intensive care units (ICUs) are particularly complex due to the influx of data to the healthcare professionals who are providing continuous care to the most critically ill patients. Systems that are designed to work in these environments should take into consideration varied patient conditions, the clinical professionals who use these systems, and the features and performance requirements that will support their efforts to provide care to their patients. We suggest that developing systems that will meet these challenges requires customized design approach, including cognitive system engineering. Until recently, this work domain has been largely ignored by manufacturers of patient monitoring systems. This panel brought together two separate teams who have been using such an approach independently to design new systems for information integration and display in ICU settings. The goals of this panel discussion were to take a close look at the tools and methods that are being used for such a cognitive system engineering approach to the design processes, and to review the recommendations and concepts that are emerging from these processes from each of the two independent teams. This paper summarizes the presentations made during the panel by the two teams regarding updates of ongoing work followed by a lively discussion between panelists and the symposium participants in the audience. Each team had its unique design process that was customized to the specific target ICU, the available resources and goals. The designed systems have original features that evolve from the unique needs of the target unit, yet the designs also share some common features.

Effective handover communication: Do we need more evidence?

Department of Medicine, Queen’s University, Kingston, Ontario Correspondence: Dr Roy Ilan, Department of Medicine, Queen’s University, 94 Stuart Street, Etherington Hall, Room 1005, Kingston, Ontario K7L 3N6. Telephone 613 484-8877, e-mail ilanr@queensu.ca The transition of a patient from the intensive care unit (ICU) to a hospital ward is one of the more complex handover scenarios in health care, and one that carries a host of potential hazards for patients. The decreased level of supervision and monitoring on the ward may result in delays in identifying and managing urgent problems. The available resources, as well as non-ICU providers’ clinical skill and expertise, may fail to meet the patient’s needs. Clinical teams would typically have limited information about, and experience with, the patient; this lack of reference point may result in failure to recognize and respond to meaningful clinical changes. Furthermore, management plans developed while the patient was in the ICU risk not being implemented as intended. As a result, ICU survivors and their families are commonly left with a sense of abandonment, mistrust of the hospital system, fear and anxiety. An effective handover process between providers in the ICU and on the ward can address various sources of harm, and foster a patientcentred continuity of care. However, because methodological limitations are very common in the published literature, how to make handover effective is yet to be explored (1). Mounting evidence suggests that improving handover communication requires a cultural change and a multifaceted strategy, including education, appropriate supervision of trainees (when applicable), integration of electronic and other tools into providers’ workflow, and a restructuring of routine processes (2). However, establishing such changes in a given system outside of a funded research context, and sustaining them over time, is very challenging. In the current issue of the Journal, Li et al (3) (pages 109-118) describe the perceptions of Canadian ICU administrators, as well as very small samples of ICU providers from Canada, the United States and the United Kingdom, regarding routine discharge practices in their hospitals. The responses indicate substantial variability among ICUs in discharge processes, an overall perceived mediocre quality of discharge practices and much-needed insights regarding improvement. Generally, self-reporting in surveys conducted for studies of this nature frequently exceeds the actually practiced behaviour. Therefore, the extent of the problem is likely greater than portrayed in this study: the effectiveness of communication between relevant stakeholders around ICU discharge is likely suboptimal for many critically ill patients. Handover communication failures occasionally result in preventable patient safety incidents. Additional research may shed light on different aspects of this problem. It is important to explore how specific interventions can address the needs of the different stakeholders involved, and can ensure a seamless transition of care and optimal management of patients’ acute and chronic conditions post-ICU discharge. However, I would strongly recommend against waiting for ‘golden’ scientific evidence before taking action. It is difficult to establish the cause-effect relationship between communication failures and downstream safety incidents. Similarly, substantial methodological limitations are inherent to the study of handover. Nevertheless, there is consensus about the importance of an effective handover process. The real challenge has more to do with system and behavioural adaptation than with the available scientific evidence. Change is needed on the ground – not in the academic ivory towers of study and research. In this case, quality improvement strategies are the solution. ICU leaders with intimate knowledge of their specific environments should design, incrementally implement, and evaluate the effectiveness of interventions to ensure that handover occurs consistently on ICU discharge; that the preferred in-person communication is supported by concise written materials; that supporting electronic and other tools, such as checklists and reminders, are user-centred; and that the various needs of each stakeholder, specifically patients and their families, are addressed in the process. Locally available resources should be used and barriers should be eliminated. The importance of continuity of care after ICU discharge cannot be overemphasized. Li et al show us that there is a lot of work ahead.