The impact of enhanced cleaning within the intensive care unit on contamination of the near-patient environment with hospital pathogens: A randomized crossover study in critical care units in two hospitals*

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.

Download Full-text

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.

Download Full-text

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.

Download Full-text

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.

Download Full-text

The impact of critical care transition programs on outcomes after intensive care unit (ICU) discharge: can we get there from here?

Journal of Thoracic Disease ◽

10.21037/jtd.2016.05.30 ◽

2016 ◽

Vol 8 (7) ◽

pp. 1374-1376 ◽

Cited By ~ 3

Author(s):

Regis Goulart Rosa ◽

Juçara Gasparetto Maccari ◽

Ricardo Viegas Cremonese ◽

Tulio Frederico Tonietto ◽

Rafael Viegas Cremonese ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Transition Programs ◽

Care Transition ◽

Icu Discharge ◽

The Impact

Download Full-text

Answering the Call: Impact of Tele-ICU Nurses During the COVID-19 Pandemic

Critical Care Nurse ◽

10.4037/ccn2020126 ◽

2020 ◽

Vol 40 (4) ◽

pp. 25-31 ◽

Cited By ~ 2

Author(s):

Sandy L. Arneson ◽

Sara J. Tucker ◽

Marie Mercier ◽

Jaspal Singh

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Intensive Care Units ◽

Holistic Approach ◽

Critical Care Units ◽

Work From Home ◽

New Strategy ◽

High Level ◽

Intensive Care Unit Nurses

Background The coronavirus disease 2019 pandemic has exacerbated staffing challenges already facing critical care nurses in intensive care units. Many intensive care units have been understaffed and the majority of nurses working in these units have little experience. Objective To describe how the skilled tele–intensive care unit nurses in our health system quickly changed from a patient-focused strategy to a clinician-focused approach during the coronavirus disease 2019 crisis. Methods We modified workflows, deployed home workstations, and changed staffing models with the goal of providing additional clinical support to bedside colleagues while reducing exposure time and conserving personal protective equipment for those caring for this highly contagious patient population. The unit changed focus and granted more than 300 clinicians access to technology that enabled them to care for patients remotely, added nearly 200 mobile carts, and allowed more than 20 tele–intensive care unit nurses to work from home. Results Tele–intensive care unit nursing provided clinical knowledge to the nurses covering current and expanded critical care units. Using technology, virtual rounding, and increased collaboration with nurses, tele–intensive care unit nursing minimized the risk to bedside nurses while maintaining a high level of care for patients. Conclusion Tele–intensive care unit nurses provided a proactive, holistic approach to caring for critically ill patients via camera as part of their routine workflow. In addition, during the coronavirus disease 2019 pandemic, these nurses created a new strategy in virtual health care to be implemented during a crisis.

Download Full-text

Telenursing in the Intensive Care Unit: Transforming Nursing Practice

Critical Care Nurse ◽

10.4037/ccn2012525 ◽

2012 ◽

Vol 32 (6) ◽

pp. 62-69 ◽

Cited By ~ 18

Author(s):

Lisa-Mae Williams ◽

Kenneth E. Hubbard ◽

Olive Daye ◽

Connie Barden

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Nursing Practice ◽

Care Patient ◽

Critical Care Nursing ◽

Telecommunication Technology ◽

Use Of Technology ◽

The Impact ◽

Care Nursing

In tele–intensive care units, informatics, telecommunication technology, telenursing, and telemedicine are merged to provide expert, evidence-based, and cutting-edge services to critically ill patients. Telenursing is an emerging subspecialty in critical care that is neither well documented in the extant literature nor well understood within the profession. Documentation and quantification of telenursing interventions help to clarify the impact of the telenurse’s role on nursing practice, enhancement of patient care, patient safety, and outcomes. Tele–intensive care unit nursing will continue to transform how critical care nursing is practiced by enhancing/leveraging available resources through the use of technology.

Download Full-text

Critical Care for the Surgical Patient

British Journal of Perioperative Nursing (United Kingdom) ◽

10.1177/175045890201200703 ◽

2002 ◽

Vol 12 (7) ◽

pp. 258-265 ◽

Cited By ~ 4

Author(s):

Chris Aps

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Cardiac Surgery ◽

Intensive Care ◽

Postoperative Management ◽

Surgical Patient ◽

Care Provision ◽

Fast Tracking ◽

Patient Dependency ◽

The Impact

Dr Chris Aps has been involved, since the early 1980s, with the impact of the surgical patient on critical care provision. At that time, he established clinical techniques to lower patient dependency after cardiac surgery. This allowed for the postoperative management of such patients in a general recovery facility rather than in the formal Intensive Care Unit (ICU). This became known as cardiac fast-tracking and led to the development of the Overnight Intensive Recovery (OIR) concept.

Download Full-text

Nurse-physician collaboration in an intensive care unit

American Journal of Critical Care ◽

10.4037/ajcc2001.10.5.341 ◽

2001 ◽

Vol 10 (5) ◽

pp. 341-350 ◽

Cited By ~ 66

Author(s):

PA Miller

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Quality Improvement ◽

National Study ◽

Improvement Program ◽

Critical Care Units ◽

Improvement Programs ◽

Nurses And Physicians ◽

Collaborative Interaction

BACKGROUND: Collaborative interaction between nurses and physicians on critical care units is significantly related to mortality rates and length of stay in the units. For this reason, collaborative interaction should be an integral part of quality improvement programs. OBJECTIVES: To examine perspectives of nurses and physicians on collaborative interaction in an intensive care unit, to examine differences between groups in perceptions of collaborative interaction in the unit, and to compare this unit with units examined in a national study. METHODS: A modification of the ICU Nurse-Physician Questionnaire was used to collect data from 35 nurses and 45 physicians. Descriptive statistics and analysis of variance were used to determine group scores and to examine differences between groups. RESULTS: The level of collaborative interaction in the unit was high. However, nurses and physicians and all other staff groups examined except one had significant differences in perceptions of collaborative interaction. The high level of collaborative interaction was confirmed by a comparison of the results with the results from a national sample. CONCLUSIONS: Critical care units can use this example to incorporate an assessment of the level of collaborative interaction into their quality improvement program.

Download Full-text