Family Communication in the Icu: Challenges and Solutions

INTRODUCTION: The COVID-19 pandemic created major barriers to communication with patient families, impacting patient care and staff satisfaction. We surveyed an interprofessional group of medical intensive care unit (MICU) stakeholders to identify their concerns surrounding family communication and solicited recommendations for performance improvement. METHOD(S): An anonymous survey was distributed electronically to 260 MICU physicians, advanced practice providers (APPs), nurses, and physical, occupational, and respiratory therapists, with a 1 week reminder. The results were analyzed using thematic analysis. RESULT(S): Thirty-nine participants (response rate 15%) completed the survey, providing 95 unique comments. Major themes included challenges created by visitor policy restrictions (providers unable to connect well with families by phone;families not understanding how to work video platforms;frequent misunderstandings);medical system distrust (antivaccine and overall hostility, unrealistic expectations, challenging treatment decisions);trainee communication concerns (lack of communication training, not seeing the "big picture", nurse not knowing whether families were contacted/what was discussed), and A2F bundle failures (F component not organized, family updates too infrequent, distorted messages). This feedback prompted a quality improvement initiative to strengthen our family communication process. The responsible resident or APP is now encouraged to use a "Get to Know Me Board" to structure the collection of relevant social history with patient and family on admission, establishing an initial relationship and line of communication. Our rounding template was modified to discuss the family communication plan each day using a tiered structure (brief summary/introduction on admission;update;serious update/acute event;goals of care;transition to comfort) and clarify which team members will be present for the conversation. Afternoon rounds were also modified to routinely confirm successful family contact and address any concerns. CONCLUSION(S): We describe the results of our interprofessional survey to define the barriers to family communication during the COVID-19 pandemic, and process improvements in our MICU to make daily family involvement and contact feasible and efficient within our daily workflow.

Stop-Virus Collaborative: A Qualitative Analysis to Forming a Virtual Landscape of Practice

INTRODUCTION: The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 (STOP-VIRUS) Collaborative was a virtual adaptation to healthcare collaboration and quality improvement during COVID-19 pandemic. The learning that happens in this space is complex, nuanced, and multi-dimensional, best explained using Wenger's social learning theory of the Landscape of Practice, where one needs knowledgeability and the ability to identify and cross the boundaries to achieve learning. METHOD(S): We conducted a qualitative study using thematic analysis to explore STOP-VIRUS participants' perspective on their experience. We used identified themes to inform the creation of the continuum of readiness for change to better characterize common challenges that institutions face at different QI readiness stages. We used a blended framework of the ADKAR model for changes start at the individual level, McKinsey's 7S framework to focus our efforts on different components necessary for change at the organizational level, and the overarching theory of landscape of practice to guide analysis and development of our conceptual framework. RESULT(S): We constructed a blended conceptual framework based on the ADKAR stages of change and the necessary components for successful change implementation based on the McKinsey's 7S framework. The 7S framework effectively demonstrates a systematic and comprehensive approach to change on an organizational level, including the 7 constructs: staff, style/culture, skills, strategy, systems, structure, with shared culture at the center of change. However, change starts at the individual level. Within the STOP-VIRUS Collaborative, the participants from each site are the catalyst for change. As a result, this is reflected through the stages of change embodied in the ADKAR model: awareness, desire, knowledge, ability, and reinforcement. Together, they provided a continuum that enable individual healthcare providers to impact change on an organization level. CONCLUSION(S): STOP-VIRUS collaborative was a multicenter, interprofessional, and diverse learning environment that re-emphasized best-practice guidelines. It provides valuable support to institutions at various stages of readiness for quality improvement initiatives, with important lessons that can be applied to future virtual collaboratives.

Gaps in Documented Assessments at the Time of Intensive Care Unit Admission

RATIONALE During this unprecedented COVID-19 pandemic intensive care units (ICU) need efficient ways to deliver patient care. As hospital workload increases, so does the risk for medical error and delays in care. A systematic initial approach and timely documentation is important to provide an efficient and thorough assessment and to facilitate communication within the interprofessional team. We aimed to evaluate documentation of key assessment elements at ICU admission. METHODS The Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) is a validated tool that reduces errors in the initial assessment and ongoing care of critically ill patients. With Mayo IRB approval, electronic medical records (EMR) of a convenience sample of ICU patients admitted to medical, surgical and mixed ICUs at our institution during October 2021 were reviewed to assess documentation of the CERTAIN primary survey, including assessment of airway, breathing, cardiac, disability, and exposure (ABCDE);vital signs;intravenous access;point of care labs and ultrasound (POCUS);differential diagnosis;and plan by systems including code status and goals of care. Patients admitted for post-operative monitoring and those who declined the use of their medical records for research were excluded. RESULTS Forty patient EMRs were reviewed. Median age was 65 years, 47.5% were female, and respiratory failure was the most common reason for ICU admission. Documented frequency of airway assessment was 32.5%, breathing 92.5%, cardiac 70%, disability 42.5%, and exposure 85%. Thorough vital sign review including temperature was documented in 47.5% of ICU admissions. A comment or plan for intravenous or intraosseous access was documented in 75% of patients. Completion or review of same day point of care labs was documented in 55%. Cardiac POCUS was documented in 9 of 40 ICU admissions. No patients had documented lung or abdominal POCUS. 80% had a differential diagnosis documented as part of their initial assessment. All patients had a complete plan by systems. 85% of patients had a documented code status, although it was unclear if it had been actively re-addressed on ICU admission. CONCLUSION EMR documentation of key findings at the time of ICU admission leaves significant opportunities for improvement, with particularly large gaps in primary survey and POCUS assessment. The results of this study, combined with ongoing direct observation of ICU admissions using the CERTAIN checklist, will inform future recommendations to improve the performance and documentation of key assessment elements during the “golden first hour” of ICU admission.

USE OF VIRAL FILTER TO REDUCE EXPOSURE TO EXHALED AEROSOL DOES NOT AFFECT METHACHOLINE DOSE DELIVERY DURING BRONCHOPROVOCATION TESTING

TOPIC: Respiratory Care TYPE: Original Investigations PURPOSE: Methacholine challenge testing (MCT) is a common bronchoprovocation technique used to assess airway hyperresponsiveness. Current ERS guidelines recommend that measures should be taken to minimize technician exposure to methacholine aerosol, with added infection control concerns in the context of the ongoing COVID-19 pandemic. We previously demonstrated that the addition of a viral filter to the nebulizer exhalation limb reduced expelled particle concentrations by 77-91% during MCT. Our aim was to evaluate whether this modification resulted in a change in the delivered dose of methacholine. METHODS: Following published industry testing standards for MCT, we connected a Hamilton-G5 mechanical ventilator and Michigan lung simulator in series with respiratory rate 15 breaths/min, tidal volume (VT) 500 mL, I:E ratio 1:1 with a sinusoidal waveform. We compared methacholine dose delivery using the Hudson MicroMist and AeroEclipse II BAN nebulizers powered by either a dry gas source at 50 psi and 4.5 L/min or the Ombra compressor system, in addition to our current MCT protocol which utilizes Hudson MicroMist nebulizer with KoKo dosimeter (3 breaths). A filter placed in line between the nebulizer and test lung was weighed before and after 1 minute of nebulized methacholine delivery. Mean inhaled mass was calculated from three trials of each method with and without a viral filter on the exhalation limb. Dose delivery was calculated by multiplying the mean inhaled mass by the respirable fraction (particles < 5 µm) and inhalation time. Unpaired t-test was used to compare methacholine dose delivery with and without viral filter placement. Due to multiple independent comparisons, Bonferroni correction was used and alpha level was set at 0.01. RESULTS: The addition of a viral filter did not significantly affect methacholine dose delivery across all devices tested. Using the 50 psi dry gas source, dose delivered with the Hudson MicroMist did not differ with (461.0 µg) or without (307.8 µg) a viral filter (P=0.11) or with the AeroEclipse II BAN with (580.8 µg) or without (678.4) a viral filter (P=0.59). Using the Ombra compressor, dose delivered with the Hudson MicroMist did not differ with (1063.3 µg) or without (947.5 µg) a viral filter (P=0.026) or with AeroEclipse II BAN with (843.8 µg) or without (648.3) viral filter (P=0.42). Dose delivery did not differ significantly when using the KoKo dosimeter and Hudson MicroMist with or without a viral filter (P=0.20) using a 3-breath protocol. CONCLUSIONS: The addition of a viral filter to the nebulizer expiratory limb did not result in a significant change in the in the delivered dose of methacholine. CLINICAL IMPLICATIONS: Based on these findings, use of a viral filter to limit the concentration of expelled aerosol during MCT should be considered to improve pulmonary function technician safety and potentially reduce the risk of infectious exposure during the ongoing COVID-19 pandemic. DISCLOSURES: No relevant relationships by Kaiser Lim, source=Web Response no disclosure submitted for todd meyer;No relevant relationships by Alexander Niven, source=Web Response No relevant relationships by Paul Scanlon, source=Web Response No relevant relationships by Yosuf Subat, source=Web Response No relevant relationships by Keith Torgerud, source=Web Response

A GLOBAL REMOTE QUALITY IMPROVEMENT INITIATIVE: NEEDS ASSESSMENT FROM INTERPROFESSIONAL CRITICAL CARE PROVIDERS FROM BOSNIA AND HERZEGOVINA

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: The need for swift international collaboration alongside rapidly deployable remote medical knowledge transition and implementation programs has been highlighted during the ongoing COVID-19 pandemic. Virtual programs have emerged as cost-effective alternatives to in-person education to spread best practices to resource-limited locations and garner purposeful learner engagement. Understanding local practice needs is paramount to the development of an effective quality improvement initiative. This study aimed to gain insight into the interests, clinical challenges, and attitudes of a group of interprofessional critical care providers from Bosnia and Herzegovina in preparation for a longitudinal remote education and quality improvement program. METHODS: A novel learning needs assessment tool was implemented in a cohort of critical care professionals from four hospitals in Bosnia and Herzegovina. A sequential explanatory design was employed, and a mixed-method assessment was conducted in three phases. 1) Utilizing the Delphi method, twenty statements containing common critical care entrustable professional activities (EPAs) were developed by a board of intensivists and medical education specialists. 2) Local learners used Q Sort methodology to rank-order EPAs based on self-perceived learning priorities, with subsequent by-person factor analysis. 3) Learners were invited for focus-group interviews to gather details of the rationale behind their rankings. RESULTS: Forty nine out of 105 participants completed the rank-order survey (response rate 47%). Factor analysis categorized the participants into two main groups based on the typology of their opinions, 22 participants into factor 1 and 9 participants into factor 2. The highest-ranked EPAs amongst the two factors were “evaluation and management of the patients with shock, stabilization, and resuscitation of critically ill patients” and “evaluation and management of ARDS,” respectively. Statements regarding common ICU complications and procedures were regarded as neutral. The lowest rank amongst factor 1 was “patient-centered care, communication skills, and interprofessional collaboration.” Participants in factor 2 ranked “preoperative evaluation and management” and “common hematologic and oncologic complications” the lowest. The rationale behind rank orders focused on the current patient population and perceived EPA importance to critical care practice. Participants in factor 1 displayed pessimistic attitudes toward patient-centered care and interprofessional collaboration due to cultural and healthcare system constraints. Interviewees in both factors described local challenges and expressed a need for change. CONCLUSIONS: We conducted a remote needs assessment in an international, interprofessional group of critical care providers. In addition to building trust with learners, the acquired knowledge of cultural differences, needs, and barriers to implementation will guide an ongoing remote education and quality improvement initiative. CLINICAL IMPLICATIONS: This investigation will shape a critical care best practices quality improvement initiative and remote education program in a country with limited resources. DISCLOSURES: No relevant relationships by Marija Bogojevic, source=Web Response No relevant relationships by Yue Dong, source=Web Response Patent/IP rights for a licensed product relationship with Ambient Clinical Analytics Please note: From 2016 Added 05/23/2021 by Ognjen Gajic, source=Web Response, value=Royalty no disclosure on file for Pedja Kovacevic;No relevant relationships by Heyi Li, source=Web Response No relevant relationships by Aida Mujakovic, source=Web Response No relevant relationships by Alexander Niven, source=Web Response No relevant relationships by Manja Spahalic, source=Web Response no disclosure on file for Slavenka Straus;No relevant relationships by Simon Zec, source=Web Response

IMPLEMENTATION OF A GLOBAL REMOTE INTERPROFESSIONAL QUALITY IMPROVEMENT INITIATIVE: RESULTS OF A NEEDS ASSESSMENT CONDUCTED FOR A BALKAN LEARNING COLLABORATIVE

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Background: The ongoing COVID-19 pandemic has created an urgent need for international collaboration and programs to rapidly share evolving medical knowledge and implementation strategies. Virtual programs offer a cost-effective option to provide meaningful engagement and disseminate best practices to remote locations with limited resources. A thorough understanding of the local practice needs is essential to design an effective quality improvement initiative. The purpose of this study was to conduct a novel learning needs assessment among an interprofessional group of Balkan healthcare professionals to better understand their current clinical challenges, interests, and opinions to inform a longitudinal remote education and quality improvement program. METHODS: We developed and performed a learning needs assessment with a group of interprofessional healthcare providers from Montenegro. This qualitative assessment was conducted in three phases using sequential explanatory design: 1) A board of intensivists and education experts developed 20 statements describing common critical care entrustable professional activities (EPAs) using a Delphi method. 2) Local healthcare providers rank-ordered these statements using Q Sort methodology, which were analyzed using by-person factor analysis. 3) A focus group interview was performed to understand the reasoning behind participant responses and analyzed using thematic analysis. RESULTS: 24 out of 63 participants answered the survey (response rate 38%). Most participants were grouped into one factor. Surveyed participants showed the highest interest in the evaluation and management of patients with shock, resuscitation, and stabilization of critically ill patients, and evaluation and management of common critical care infections. Moderate interest was expressed for procedural skills and the evaluation and management of the most common complications in the intensive care unit. Less common priorities were communication skills and interprofessional collaboration. The focus group interviewees agreed that they need improvement in a systemic approach, better protocols, and interprofessional collaboration and provided important insights into local practice constraints and cultural values. CONCLUSIONS: We describe an effective qualitative approach to conduct a remote needs assessment among an international, interprofessional group of healthcare professionals. This information has informed a tailored instructional design of our ongoing education and quality improvement initiative and has proved crucial to building cultural appreciation, trust, and an understanding of the expectations, needs, and implementation challenges of our Balkan participants. CLINICAL IMPLICATIONS: Description of a novel learning needs assessment tool to help build a customized remote education and quality improvement initiative for an interprofessional group of critical care healthcare professionals from the Balkan. DISCLOSURES: No relevant relationships by Marija Bogojevic, source=Web Response No relevant relationships by Milan Bogojevic, source=Web Response No relevant relationships by Yue Dong, source=Web Response Patent/IP rights for a licensed product relationship with Ambient Clinical Analytics Please note: From 2016 Added 05/23/2021 by Ognjen Gajic, source=Web Response, value=Royalty No relevant relationships by Heyi Li, source=Web Response No relevant relationships by Alexander Niven, source=Web Response No relevant relationships by Zoja Stankovic, source=Web Response No relevant relationships by Simon Zec, source=Web Response

FEASIBILITY, DELIVERY, AND IMPLEMENTATION OF A REMOTE CRITICAL CARE TRAINING PROGRAM IN CHINA: THE CERTAIN APPROACH

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: To describe the development, implementation, and learner engagement in a longitudinal international remote critical care continuing medical education program in China. METHODS: Based on the Mayo Clinic Checklist for Early Recognition and Treatment of Acute and Illness and iNjury (CERTAIN) program, we designed and delivered a longitudinal 40-week remote coaching program for a community-based teaching hospital in Shandong Province, China. Based on a mixed-methods needs assessment that included learner feedback using an exploratory sequential design and ICU process and outcomes data, we developed a curriculum that included asynchronous, online learning modules with multiple language captions and weekly remote education sessions using a blend of didactic presentations on common critical care syndromes, virtual simulation, journal club, and case-based discussions. Faculty included a diverse group of critical care experts and bilingual facilitators. The program also included clinical research and quality improvement workshops to facilitate implementation of key concepts identified during these activities. Participants completed a survey using a 5 point anchored Likert scale after each educational activity to provide feedback and guide course improvement. RESULTS: Twenty-two Chinese clinicians (18 physicians, 4 nurses) enrolled in this CERTAIN longitudinal program. Learners completed a total of 163 hours (mean 7.4 hr/learner) asynchronous online learning, and to date have completed 23 weekly education sessions (total 28 hours, including an extended virtual simulation experience). Survey response rate was 56%. Learners reported a high rate of overall satisfaction with the course (112, 61% Excellent;55 (30%) Very Good) and specific topic discussions (110,60% Excellent;57, 31% Very Good), with steady improvement over time. Perceived practice relevance was also high (110, 59% Excellent;55,30% Very Good), and this effort has informed ongoing local performance improvement initiatives. CONCLUSIONS: Remote delivery of longitudinal critical care continuing education program in China using asynchronous learning, case-based discussion, and virtual simulation is feasible, associated with a high rate of learner satisfaction, and increases engagement in quality improvement initiatives. This innovative global education initiative offers an important potential solution to strengthen critical care services in remote, resource-limited settings at low cost, especially during the ongoing COVID-19 pandemic. CLINICAL IMPLICATIONS: The World Health Organization has identified remote education programs as a priority to strengthen international critical care services and better meet growing global clinical demand. The best method to effectively deliver continuing medical education to international healthcare providers with unique cultural, organizational, and practice backgrounds is not well defined. DISCLOSURES: no disclosure on file for Wenjuan Cui;No relevant relationships by Yue Dong, source=Web Response Patent/IP rights for a licensed product relationship with Ambient Clinical Analytics Please note: From 2016 Added 05/23/2021 by Ognjen Gajic, source=Web Response, value=Royalty No relevant relationships by Heyi Li, source=Web Response No relevant relationships by Alexander Niven, source=Web Response no disclosure on file for Lujun Qiao;No relevant relationships by Yuqiang Sun, source=Web Response no disclosure on file for Qingzhong Yuan;

Aerosol Generation during Peak Flow Testing: Clinical Implications during the COVID-19 Pandemic

Background: Peak flow testing is a common procedure performed in ambulatory care. There are currently no data regarding aerosol generation during this procedure. We measured small particle concentrations generated during peak flow testing. Several peak flow devices were compared to assess for differences in aerosol generation. The amount of aerosol generation should objectively inform infection control and mitigation strategies during the COVID-19 pandemic. Methods: Five healthy volunteers performed peak flow maneuvers in a particle free laboratory space. Two devices continuously sampled the ambient air during the procedure. One device can detect ultrafine particles from 0.02 - 1 micron, while the second device can detect particles of size 0.3, 0.5, 1.0, 2.0, 5.0, and 10 microns. Five different peak flow meters were compared to ambient baseline during masked and unmasked tidal breathing. Results: Ultrafine particles (0.02 - 1 micron) were generated during peak flow rate measurement. Ultrafine particle mean concentration was lowest with Respironics peak flow meter (1.25±0.47 particles/cc) and similar between Philips (3.06±1.22), Clement Clarke (3.55±1.22 particles/cc), Respironics low range (3.50±1.52 particles/cc), and Monaghan (3.78±1.31 particles/cc) peak flow meters. Although ultrafine particle mean concentration increased during peak flow measurements compared ambient baseline during masked (0.22±0.29 particles/cc) and unmasked (0.15±0.18 particles/cc) tidal breathing, these differences were small and remained well below ambient PFT room particle concentrations (89.9±8.95 particles/cc). Conclusions: In this study, we were able to establish the feasibility of measuring small particle production after peak flow testing. Our study shows that ultrafine particles are generated during peak flow measurement. Although all peak flow meters demonstrated increased mean particle concentration, differences were small compared to the mean particle concentrations found in the ambient clinical environment. Outpatient practices should be aware of the potential risk of these findings and take appropriate infection control precautions.

An implementation and longitudinal evaluation framework of remote quality improvement initiatives

Objective: Virtual learning experiences have become widely used during the ongoing COVID-19 global crisis. Given its cost-effectiveness, accessibility, and flexibility, remote training experiences are likely to assume a permanent and expanded role in medical education and quality improvement initiatives. However, little is known about how best to measure the effectiveness of remote training interventions. The Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) is an established critical care quality improvement program with evidence of improved care processes and patient outcomes in an international quality improvement trial. Our aim was to develop a structured implementation and longitudinal evaluation framework that measures the complex contributors to the impact of this remote training program, including incorporation into processes of care and sustainment over time. Methods: We convened an international topic review group that included individuals with diversity in clinical expertise, nationality, and experience in medical education, quality improvement, implementation science, and research methodology. We recruited individuals with experience designing and participating in various medical remote training programs, including teleconferences, tele-consults, online video/chat platforms, and virtual simulation classrooms. Through a series of facilitated discussions, we directed the group to develop a conceptual framework to guide the development of remote learning programs and accompanying evaluation tools to measure their impact. Results: The review group members included education experts and continuing medical education participants from China and the United States with practice backgrounds in Critical Care, Internal Medicine, Anesthesiology and Emergency Medicine. The group developed a conceptual framework based on the CIPP (context-input-process-product) quality evaluation model. The framework includes three phases: before, during, and after the remote training. The proposed quantitative and qualitative evaluation tools blend the Proctor taxonomy, an expansion of the popular RE-AIM framework used to categorize implementation outcomes, to include early (i.e. acceptability, appropriateness, feasibility), mid (i.e. adoptions, fidelity), and late (i.e. sustainability) stage outcomes to provide a more complete understanding of the implementation process and facilitate generalization of our findings. Elements of the Logic Model were also used to guide the program development process. Conclusions: We propose a dynamic, longitudinal implementation evaluation framework that has sufficient rigor and flexibility to meet the needs of the existing and emerging remote medical training programs in global practice settings. The outcomes from these mixed-methods analyses will provide a robust toolbox to guide the design, delivery, implementation, and sustainment of remote medical educational programs.