The Impact of Changes to an Electronic Admission Order Set on Prescribing and Clinical Outcomes in the Intensive Care Unit

Abstract Background Implementation of disease-specific order sets has improved compliance with standards of care for a variety of diseases. Evidence of the impact admission order sets can have on care is limited. Objective The main purpose of this article is to evaluate the impact of changes made to an electronic critical care admission order set on provider prescribing patterns and clinical outcomes. Methods A retrospective, observational before-and-after exploratory study was performed on adult patients admitted to the medical intensive care unit using the Inpatient Critical Care Admission Order Set. The primary outcome measure was the percentage change in the number of orders for scheduled acetaminophen, a histamine-2 receptor antagonist (H2RA), and lactated ringers at admission before implementation of the revised order set compared with after implementation. Secondary outcomes assessed clinical impact of changes made to the order set. Results The addition of a different dosing strategy for a medication already available on the order set (scheduled acetaminophen vs. as needed acetaminophen) had no impact on physician prescribing (0 vs. 0%, p = 1.000). The addition of a new medication class (an H2RA) to the order set significantly increased the number of patients prescribed an H2RA for stress ulcer prophylaxis (0 vs. 20%, p < 0.001). Rearranging the list of maintenance intravenous fluids to make lactated ringers the first fluid option in place of normal saline significantly decreased the number of orders for lactated ringers (17 vs. 4%, p = 0.005). The order set changes had no significant impact on clinical outcomes such as incidence of transaminitis, gastrointestinal bleed, and acute kidney injury. Conclusion Making changes to an admission order set can impact provider prescribing patterns. The type of change made to the order set, in addition to the specific medication changed, may have an effect on how influential the changes are on prescribing patterns.

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The Impact of Implementing a “Pain, Agitation, and Delirium Bundle” in a Pediatric Intensive Care Unit: Improved Delirium Diagnosis

Journal of Pediatric Intensive Care ◽

10.1055/s-0041-1723037 ◽

2021 ◽

Author(s):

Lise D. Cloedt ◽

Kenza Benbouzid ◽

Annie Lavoie ◽

Marie-Élaine Metras ◽

Marie-Christine Lavoie ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Pediatric Intensive Care Unit ◽

Pediatric Intensive Care ◽

Post Intervention ◽

Number Of Patients ◽

Implementation Period ◽

Short And Long Term ◽

The Impact

AbstractDelirium is associated with significant negative outcomes, yet it remains underdiagnosed in children. We describe the impact of implementing a pain, agitation, and delirium (PAD) bundle on the rate of delirium detection in a pediatric intensive care unit (PICU). This represents a single-center, pre-/post-intervention retrospective and prospective cohort study. The study was conducted at a PICU in a quaternary university-affiliated pediatric hospital. All patients consecutively admitted to the PICU in October and November 2017 and 2018. Purpose of the study was describe the impact of the implementation of a PAD bundle. The rate of delirium detection and the utilization of sedative and analgesics in the pre- and post-implementation phases were measured. A total of 176 and 138 patients were admitted during the pre- and post-implementation phases, respectively. Of them, 7 (4%) and 44 (31.9%) were diagnosed with delirium (p < 0.001). Delirium was diagnosed in the first 48 hours of PICU admission and lasted for a median of 2 days (interquartile range [IQR]: 2–4). Delirium diagnosis was higher in patients receiving invasive ventilation (p < 0.001). Compliance with the PAD bundle scoring was 79% for the delirium scale. Score results were discussed during medical rounds for 68% of the patients in the post-implementation period. The number of patients who received opioids and benzodiazepines and the cumulative doses were not statistically different between the two cohorts. More patients received dexmedetomidine and the cumulative daily dose was higher in the post-implementation period (p < 0.001). The implementation of a PAD bundle in a PICU was associated with an increased recognition of delirium diagnosis. Further studies are needed to evaluate the impact of this increased diagnostic rate on short- and long-term outcomes.

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The Impact of Implementing Critical Care Team on Open General Intensive Care Unit

Tuberculosis and Respiratory Diseases ◽

10.4046/trd.2012.73.2.100 ◽

2012 ◽

Vol 73 (2) ◽

pp. 100 ◽

Cited By ~ 1

Author(s):

Ick Hee Kim ◽

Seung Bae Park ◽

Seonguk Kim ◽

Sang-Don Han ◽

Seung Seok Ki ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Care Team ◽

General Intensive Care Unit ◽

The Impact ◽

Critical Care Team

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The Benefits of Parenteral Nutrition (PN) Versus Enteral Nutrition (EN) Among Adult Critically Ill Patients: What is the Evidence? A Literature Review

Journal of Intensive Care Medicine ◽

10.1177/0885066619843782 ◽

2019 ◽

Vol 35 (7) ◽

pp. 615-626 ◽

Cited By ~ 2

Author(s):

Angel Joel Cadena ◽

Sara Habib ◽

Fred Rincon ◽

Stephanie Dobak

Keyword(s):

Health Care ◽

Intensive Care Unit ◽

Intensive Care ◽

Enteral Nutrition ◽

Parenteral Nutrition ◽

Clinical Outcomes ◽

Critically Ill ◽

Nutrition Support ◽

Mechanical Ventilation Duration ◽

The Impact

Malnutrition is frequently seen among patients in the intensive care unit. Evidence shows that optimal nutritional support can lead to better clinical outcomes. Recent clinical trials debate over the efficacy of enteral nutrition (EN) over parenteral nutrition (PN). Multiple trials have studied the impact of EN versus PN in terms of health-care cost and clinical outcomes (including functional status, cost, infectious complications, mortality risk, length of hospital and intensive care unit stay, and mechanical ventilation duration). The aim of this review is to address the question: In critically ill adult patients requiring nutrition support, does EN compared to PN favorably impact clinical outcomes and health-care costs?

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Patient length of stay and mortality prediction: A survey

Health Services Management Research ◽

10.1177/0951484817696212 ◽

2017 ◽

Vol 30 (2) ◽

pp. 105-120 ◽

Cited By ~ 16

Author(s):

Aya Awad ◽

Mohamed Bader–El–Den ◽

James McNicholas

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Length Of Stay ◽

Length Of Hospital Stay ◽

Hospital Performance ◽

Mortality Prediction ◽

Cost Of Care ◽

Resource Utilisation ◽

Number Of Patients

Over the past few years, there has been increased interest in data mining and machine learning methods to improve hospital performance, in particular hospitals want to improve their intensive care unit statistics by reducing the number of patients dying inside the intensive care unit. Research has focused on prediction of measurable outcomes, including risk of complications, mortality and length of hospital stay. The length of stay is an important metric both for healthcare providers and patients, influenced by numerous factors. In particular, the length of stay in critical care is of great significance, both to patient experience and the cost of care, and is influenced by factors specific to the highly complex environment of the intensive care unit. The length of stay is often used as a surrogate for other outcomes, where those outcomes cannot be measured; for example as a surrogate for hospital or intensive care unit mortality. The length of stay is also a parameter, which has been used to identify the severity of illnesses and healthcare resource utilisation. This paper examines a range of length of stay and mortality prediction applications in acute medicine and the critical care unit. It also focuses on the methods of analysing length of stay and mortality prediction. Moreover, the paper provides a classification and evaluation for the analytical methods of the length of stay and mortality prediction associated with a grouping of relevant research papers published in the years 1984 to 2016 related to the domain of survival analysis. In addition, the paper highlights some of the gaps and challenges of the domain.

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Monitoring intensive care unit performance—impact of a novel individualised performance scorecard in critical care medicine: a mixed-methods study protocol

BMJ Open ◽

10.1136/bmjopen-2017-019165 ◽

2018 ◽

Vol 8 (1) ◽

pp. e019165 ◽

Cited By ~ 5

Author(s):

Shannon M Fernando ◽

David Neilipovitz ◽

Aimee J Sarti ◽

Erin Rosenberg ◽

Rabia Ishaq ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Mixed Methods ◽

Performance Metrics ◽

Quality Standard ◽

Care Patient ◽

Critical Care Medicine ◽

Resource Utilisation ◽

The Impact

IntroductionPatients admitted to a critical care medicine (CCM) environment, including an intensive care unit (ICU), are susceptible to harm and significant resource utilisation. Therefore, a strategy to optimise provider performance is required. Performance scorecards are used by institutions for the purposes of driving quality improvement. There is no widely accepted or standardised scorecard that has been used for overall CCM performance. We aim to improve quality of care, patient safety and patient/family experience in CCM practice through the utilisation of a standardised, repeatable and multidimensional performance scorecard, designed to provide a continuous review of ICU physician and nurse practice, as well as departmental metrics.Methods and analysisThis will be a mixed-methods, controlled before and after study to assess the impact of a CCM-specific quality scorecard. Scorecard metrics were developed through expert consensus and existing literature. The study will include 19 attending CCM physicians and approximately 300 CCM nurses. Patient data for scorecard compilation are collected daily from bedside flow sheets. Preintervention baseline data will be collected for 6 months for each participant. After this, each participant will receive their scorecard measures. Following a 3-month washout period, postintervention data will be collected for 6 months. The primary outcome will be change in performance metrics following the provision of scorecard feedback to subjects. A cost analysis will also be performed, with the purpose of comparing total ICU costs prior to implementation of the scorecard with total ICU costs following implementation of the scorecard. The qualitative portion will include interviews with participants following the intervention phase. Interviews will be analysed in order to identify recurrent themes and subthemes, for the purposes of driving scorecard improvement.Ethics and disseminationThis protocol has been approved by the local research ethics board. Publication of results is anticipated in 2019. If this intervention is found to improve patient- and unit-directed outcomes, with evidence of cost-effectiveness, it would support the utilisation of such a scorecard as a quality standard in CCM.

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Rapid Implementation and Innovative Applications of a Virtual Intensive Care Unit During the COVID-19 Pandemic: Case Study (Preprint)

10.2196/preprints.20143 ◽

2020 ◽

Author(s):

Atiya Dhala ◽

Farzan Sasangohar ◽

Bita Kash ◽

Nima Ahmadi ◽

Faisal Masud

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Care Delivery ◽

Care Physician ◽

Rapid Expansion ◽

Code Blue ◽

Scope Of Application ◽

Spread Of Infection ◽

The Impact

BACKGROUND The COVID-19 pandemic has necessitated a rapid increase of space in highly infectious disease intensive care units (ICUs). At Houston Methodist Hospital (HMH), a virtual intensive care unit (vICU) was used amid the COVID-19 outbreak. OBJECTIVE The aim of this paper was to detail the novel adaptations and rapid expansion of the vICU that were applied to achieve patient-centric solutions while protecting staff and patients’ families during the pandemic. METHODS The planned vICU implementation was redirected to meet the emerging needs of conversion of COVID-19 ICUs, including alterations to staged rollout timing, virtual and in-person staffing, and scope of application. With the majority of the hospital critical care physician workforce redirected to rapidly expanded COVID-19 ICUs, the non–COVID-19 ICUs were managed by cardiovascular surgeons, cardiologists, neurosurgeons, and acute care surgeons. HMH expanded the vICU program to fill the newly depleted critical care expertise in the non–COVID-19 units to provide urgent, emergent, and code blue support to all ICUs. RESULTS Virtual family visitation via the Consultant Bridge application, palliative care delivery, and specialist consultation for patients with COVID-19 exemplify the successful adaptation of the vICU implementation. Patients with COVID-19, who were isolated and separated from their families to prevent the spread of infection, were able to virtually see and hear their loved ones, which bolstered the mental and emotional status of those patients. Many families expressed gratitude for the ability to see and speak with their loved ones. The vICU also protected medical staff and specialists assigned to COVID-19 units, reducing exposure and conserving personal protective equipment. CONCLUSIONS Telecritical care has been established as an advantageous mechanism for the delivery of critical care expertise during the expedited rollout of the vICU at Houston Methodist Hospital. Overall responses from patients, families, and physicians are in favor of continued vICU care; however, further research is required to examine the impact of innovative applications of telecritical care in the treatment of critically ill patients.

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Rapid Implementation and Innovative Applications of a Virtual Intensive Care Unit During the COVID-19 Pandemic: Case Study

Journal of Medical Internet Research ◽

10.2196/20143 ◽

2020 ◽

Vol 22 (9) ◽

pp. e20143

Author(s):

Atiya Dhala ◽

Farzan Sasangohar ◽

Bita Kash ◽

Nima Ahmadi ◽

Faisal Masud

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Care Delivery ◽

Care Physician ◽

Rapid Expansion ◽

Code Blue ◽

Scope Of Application ◽

Spread Of Infection ◽

The Impact

Background The COVID-19 pandemic has necessitated a rapid increase of space in highly infectious disease intensive care units (ICUs). At Houston Methodist Hospital (HMH), a virtual intensive care unit (vICU) was used amid the COVID-19 outbreak. Objective The aim of this paper was to detail the novel adaptations and rapid expansion of the vICU that were applied to achieve patient-centric solutions while protecting staff and patients’ families during the pandemic. Methods The planned vICU implementation was redirected to meet the emerging needs of conversion of COVID-19 ICUs, including alterations to staged rollout timing, virtual and in-person staffing, and scope of application. With the majority of the hospital critical care physician workforce redirected to rapidly expanded COVID-19 ICUs, the non–COVID-19 ICUs were managed by cardiovascular surgeons, cardiologists, neurosurgeons, and acute care surgeons. HMH expanded the vICU program to fill the newly depleted critical care expertise in the non–COVID-19 units to provide urgent, emergent, and code blue support to all ICUs. Results Virtual family visitation via the Consultant Bridge application, palliative care delivery, and specialist consultation for patients with COVID-19 exemplify the successful adaptation of the vICU implementation. Patients with COVID-19, who were isolated and separated from their families to prevent the spread of infection, were able to virtually see and hear their loved ones, which bolstered the mental and emotional status of those patients. Many families expressed gratitude for the ability to see and speak with their loved ones. The vICU also protected medical staff and specialists assigned to COVID-19 units, reducing exposure and conserving personal protective equipment. Conclusions Telecritical care has been established as an advantageous mechanism for the delivery of critical care expertise during the expedited rollout of the vICU at Houston Methodist Hospital. Overall responses from patients, families, and physicians are in favor of continued vICU care; however, further research is required to examine the impact of innovative applications of telecritical care in the treatment of critically ill patients.

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Critical Care Demand and Intensive Care Supply for Patients in Japan with COVID-19 at the Time of the State of Emergency Declaration in April 2020: A Descriptive Analysis

Medicina ◽

10.3390/medicina56100530 ◽

2020 ◽

Vol 56 (10) ◽

pp. 530

Author(s):

Yosuke Fujii ◽

Kiichi Hirota

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Critical Care ◽

Intensive Care ◽

Extracorporeal Membrane Oxygenation ◽

Descriptive Analysis ◽

State Of Emergency ◽

Medical Institutions ◽

Number Of Patients ◽

Care Capacity

Background and objectives: The coronavirus disease 2019 (COVID-19) pandemic is overwhelming Japan’s intensive care capacity. This study aimed to determine the number of patients with COVID-19 who required intensive care and to compare the numbers with Japan’s intensive care capacity. Materials and Methods: Publicly available datasets were used to obtain the number of confirmed patients with COVID-19 undergoing mechanical ventilation and extracorporeal membrane oxygenation (ECMO) between 15 February and 19 July 2020 to determine and compare intensive care unit (ICU) and attending bed needs for patients with COVID-19, and to estimate peak ICU demands in Japan. Results: During the epidemic peak in late April, 11,443 patients (1.03/10,000 adults) had been infected, 373 patients (0.034/10,000 adults) were in ICU, 312 patients (0.028/10,000 adults) were receiving mechanical ventilation, and 62 patients (0.0056/10,000 adults) were under ECMO per day. At the peak of the epidemic, the number of infected patients was 651% of designated beds, and the number of patients requiring intensive care was 6.0% of ICU beds, 19.1% of board-certified intensivists, and 106% of designated medical institutions in Japan. Conclusions: The number of critically ill patients with COVID-19 continued to rise during the pandemic, exceeding the number of designated beds but not exceeding ICU capacity.

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