Integration of an ICU visualization dashboard (i-Dashboard) as a platform to facilitate multidisciplinary rounds: A cluster randomized trial (Preprint)

BACKGROUND Multidisciplinary rounds (MDRs) are scheduled, patient-focused communication mechanisms among multidisciplinary providers in the intensive care unit (ICU). OBJECTIVE i-Dashboard is a custom-developed visualization dashboard that supports 1) key information retrieval and reorganization, 2) time-series data and 3) display on large touchscreens during MDRs. The present study aimed to evaluate the performance, including the efficiency of pre-rounding data gathering, communication accuracy and information exchange, and clinical satisfaction of integrating i-Dashboard as a platform to facilitate MDRs. METHODS A cluster randomized trial was performed in two surgical ICUs at a university hospital. Study participants included all multidisciplinary care team members. The performances and clinical satisfaction of i-Dashboard during MDRs were compared with those of the established electronic medical record (EMR) through direct observation and questionnaire survey. RESULTS Between April 26, 2021, and July 18, 2021, 78 and 91 MDRs were performed with the established EMR and i-Dashboard, respectively. For pre-rounding data gathering, the median (interquartile range [IQR]) time was 10.4 (9.1-11.8) and 4.6 (3.5-5.8) minutes using the established EMR and i-Dashboard (P<.001), respectively. During MDRs, data misrepresentations were significantly less frequent with i-Dashboard (median [IQR]: 0 [0-0]) than with the established EMR (4 [3-5]; P<.001). Also, effective recommendations were significantly more frequent with i-Dashboard than with the established EMR (P<.001). The questionnaire results revealed that participants favored using i-Dashboard in association with the enhancement of care plan development and team participation during MDRs. CONCLUSIONS i-Dashboard increases the efficiency in data gathering. Displaying i-Dashboard on large touchscreens in MDRs may enhance communication accuracy, information exchange and clinical satisfaction. The design concepts of i-Dashboard may help develop visualization dashboards that are more applicable for ICU MDRs. CLINICALTRIAL ClinicalTrials.gov NCT04845698; https://clinicaltrials.gov/ct2/show/NCT04845698

Enhancing palliative care consultation workflow on an inpatient oncology unit.

208 Background: The American Society of Clinical Oncology practice guidelines recommend early palliative care integration for all patients with cancer. At UMass Memorial Medical Center from Sept. to Nov. 2020, only 16% (29/184) of patients on the inpatient oncology unit received a palliative care consultation. Of these consultations, 55% (16/29) were placed within 72 hours of admission. Results from a pre-pilot survey of nurses (n = 20) and providers (n = 14) about attitudes toward palliative care, team communication, and perceptions of barriers to palliative care consultation highlighted a lack of multidisciplinary communication and consensus on criteria for palliative care consultation. Methods: An evidence-based palliative care screening tool and multidisciplinary communication process was piloted to support team collaboration and early identification of oncology patients who may benefit from specialty-level inpatient palliative care. The primary objective was to increase the percentage of palliative care consultations placed within 72 hours of admission from 55% to 65%. Nurses screened patients upon unit arrival for palliative care needs. Patients who screened positive were discussed during daily multidisciplinary rounds, attended by the resource nurse, primary team, case manager and social worker. Results: In March 2021, the percentage of palliative care consultations placed by providers within 72 hours of inpatient admission increased to 68% (13/19). The proportion of patients who received palliative care consultation also increased to 29%. All the patients who screened positive for palliative care needs received a consultation. In a post-pilot survey of providers (n = 9) and nurses (n = 14), most providers (78%) reported that discussions of patients’ palliative care needs occurred more frequently during multidisciplinary rounds. A majority of nurses (57%) agreed the screening tool led to enhanced multidisciplinary communication. 63% of providers agreed that criteria for palliative care consultation was clearer as a result of the pilot; both nurse and provider perceptions of “lack of provider agreement on palliative care consultation criteria” as a barrier decreased compared to the pre-pilot survey. Although a majority of nurses (71%) found the screening tool easy to use, only half were comfortable with all the questions or understood them completely. All providers and 93% of nurses preferred to continue using the screening tool and communication process, and supported electronic medical record integration. Conclusions: The palliative care screening tool and workflow process had a positive impact on earlier identification of oncology patients who could benefit from specialty palliative care, and increased the total number of palliative care consultations. This improved process also enhanced team communication and collaboration. Next steps include refining the screening tool and EMR integration.

512 Bedside Transthoracic echography volume Assessment in the BICU

Introduction Point-of-Care Ultrasound (POCUS) has been shown to be a useful adjunct in assessment of various shock states and utilized to guide resuscitative and post-resuscitation de-escalation efforts. POCUS use for guiding resuscitation in burn injured patient has not be described. Objectives characterize the use of bedside ultrasound examinations performed by advance practice providers and treating physicians in a regional burn intensive care unit Methods Daily beside ultrasound examinations were performed utilizing a bedside ultrasound device by an advanced practice provider prior to rounds POCUS examinations consist of: Ultrasound images were archived to a centralized image repository and reviewed daily during multi-disciplinary rounds. Ultrasonographic volume assessment compared to clinical volume assessment made during daily multidisciplinary rounds. Results 100 examinations were performed of those 32 were within the initial 72 hour window: Conclusions Our results demonstrate that bedside ultrasound aides in guidance of both resuscitative and post-resuscitative efforts. We identified a cohort of patients who appeared hypervolemic clinically but US findings supported hypovolemia, we refer to as pseudohypervolemia US volume assessment provides information that changes management. We believe point of care ultrasound is a viable tool in preventing over-resuscitation as well as to guide post-resuscitative diuresis.

583 Burn Care During Six Months Covid-19 Pandemic; Report of A Single Center

Introduction The novel coronavirus (SARS-CoV-2) responsible for COVID-19 pandemic caused an unprecedented health care crisis. During pandemic burn centers had to preserve the ongoing burn care in a safe and ethical way. It is crucial to manage inpatients, outpatients, wards and staff carefully to prevent epidemia in burn units. Here, we aimed to report our burn care experience during the six months COVID-19 pandemic. Methods We retrospectively evaluated our ambulatory and hospitalized burn patients during the six months COVID-19 pandemic (from March to September 2020) with respect to the demographic data, wound care, surgery, intensive care management. Based on the model of our infection control team, we formed first to third degree prevention methods while contacting with burn patients in our outpatient clinic, semi-sterile ward (with beds) and intensive care unit (with 4 beds) which were sterilized and ventilated regularly. During hospitalization, we restricted the degree of interaction during multidisciplinary rounds. To screen for nosocomial infections, patients were routinely tested with PCR test. Results 402 burn patients (158 paediatric, 244 adults) were managed as outpatients (n=332;82%) and in patients (n=70; 18%) in our burn centre. Total body surface area percentage of burn in hospitalized patients were 9, 95±2, 76 % in paediatric and 25, 34±3, 49 in adult group. Majority of the burns were scald (86.7% paediatric, 60.5% adults) burns. We successfully performed 66 surgical debridement and grafting procedures. Three adult patients had mechanical ventilation support during follow up and one of them died due to multi organ failure with negative PCR. We detected COVID-19 in 2 patients and both of them were discharged successfully. Conclusions According to our results, when precautions are taken, burn care can be managed successfully without posing any risk to patients during the pandemic period.

#69: Improving Communication About the Care and Prevention of Infections in a Pediatric Oncology Unit by Using Patient Daily Goals in Multidisciplinary Rounds

Background In children with cancer infections are the most frequent complication, with fatal outcomes if not addressed promptly. Therefore, care and prevention of infections in these patients require multidisciplinary interventions, with effective communication among healthcare providers to reduce the morbidity, length of stay, and the inappropriate use of resources. We used the Institute of Healthcare Improvement (IHI) model for improving the communication among healthcare providers by using patient daily goals after the oncology pediatric unit multidisciplinary rounds. Methods A multidisciplinary team was identified in the pediatric oncology unit. The team received weekly coaching on the IHI methodology. The methodology used included the creation of a block diagram to understand the baseline processes and a key driver diagram. Then, after a literature review, a data collection plan and measures were identified. The team identified different ideas for changes and prioritized them using an impact-effort matrix. Finally, several rounds of Plan-Do-Study-Act (PDSA) cycles reached the desired changes that organized the patient daily goals for sharing in the form of a worksheet. This worksheet was shared with nurses and pharmacist staff, a chat group was created, and the routine use of the daily goals for patient management was taught and incorporated into the rest of the care team staff. The percentage of excellent communication among all multidisciplinary teams and outcomes (length of stay, intensive care unit admission, and mortality) were recorded at baseline and endline. We determined the statistical significance of the baseline vs. endline difference by using χ 2 and t-tests. Results A total of 105 patients with suspected infections were included over a 6-month period (June through November 2019). We found a significant increase per month in the percent of agreement in excellent communication in the patient daily goals between infectious diseases specialist faculty and fellows, nurses, pharmacist, and pediatric oncology faculty and fellows (33.3% vs. 91.3%) (P = 0.004). Length of stay decreased monthly after our interventions (baseline: mean 14.7 days [SD 12.4] vs. after intervention: mean 6.7 days [SD 2.7]) (P = 0.014). There were only one ICU admission and no deaths during the implementation period. Conclusions Our approach using patient daily goals improved communication among a multidisciplinary team, leading to decreased length of stay and supporting adequate outcomes.

When Is My Care Team Rounding? A Simple Signage Intervention to Increase Awareness of Rounding Times

Patient and caregiver awareness of multidisciplinary rounds (MDR) times, and their subsequent involvement in MDR, aids in decreasing adverse health outcomes, reducing average length of stay, and increasing satisfaction. The objective of this study was to increase patient and caregiver awareness of MDR times using signage interventions and to assess the state of rounding processes with patient and caregiver satisfaction pre- and post-intervention. We administered survey questions to assess MDR interaction and awareness regarding MDR times. Patient and caregiver awareness of rounding times increased significantly by 25.87% ( P = .0043) post-intervention. Although patients’ confidence in the physician remained largely unchanged after the intervention due to high initial confidence levels, MDR satisfaction metrics increased slightly post-intervention. Thus, our signage intervention increased rounding time awareness in the MDR process.

Machine-learning-based hospital discharge predictions can support multidisciplinary rounds and decrease hospital length-of-stay

BackgroundPatient flow directly affects quality of care, access and financial performance for hospitals. Multidisciplinary discharge-focused rounds have proven to minimise avoidable delays experienced by patients near discharge. The study objective was to support discharge-focused rounds by implementing a machine-learning-based discharge prediction model using real-time electronic health record (EHR) data. We aimed to evaluate model predictive performance and impact on hospital length-of-stay.MethodsDischarge prediction models were developed from hospitalised patients on four inpatient units between April 2016 and September 2018. Unit-specific models were implemented to make individual patient predictions viewable with the EHR patient track board. Predictive performance was measured prospectively for 12 470 patients (120 780 patient-predictions) across all units. A pre/poststudy design applying interrupted time series methods was used to assess the impact of the discharge prediction model on hospital length-of-stay.ResultsProspective discharge prediction performance ranged in area under the receiver operating characteristic curve from 0.70 to 0.80 for same-day and next-day predictions; sensitivity was between 0.63 and 0.83 and specificity between 0.48 and 0.80. Elapsed length-of-stay, counts of labs and medications, mobility assessments and measures of acute kidney injury were model features providing the most predictive value. Implementing the discharge predictions resulted in a reduction in hospital length-of-stay of over 12 hours on a medicine unit (p<0.001) and telemetry unit (p=0.002), while no changes were observed for the surgery unit (p=0.190) and second medicine unit (p<0.555).ConclusionsIncorporating automated patient discharge predictions into multidisciplinary rounds can support decreases in hospital length-of-stay. Variation in execution and impact across inpatient units existed.