Impact of Structured Rounding Tools on Time Allocation During Multidisciplinary Rounds: An Observational Study.

BACKGROUND: Recent research has shown evidence of disproportionate time allocation for patient communication during multidisciplinary rounds (MDRs). Studies have shown that patients discussed later during rounds receive lesser time. OBJECTIVE: The aim of our study was to investigate whether disproportionate time allocation effects persist with the use of structured rounding tools. METHODS: Using audio recordings of rounds (N=82 patients), we compared time allocation and communication breakdowns between a problem-based Subjective, Objective, Assessment, and Plan (SOAP) and a system-based Handoff Intervention Tool (HAND-IT) rounding tools. RESULTS: We found no significant linear dependence of the order of patient presentation on the time spent or on communication breakdowns for both structured tools. However, for the problem-based tool, there was a significant linear relationship between the time spent on discussing a patient and the number of communication breakdowns (P<.05)--with an average of 1.04 additional breakdowns with every 120 seconds in discussion. CONCLUSIONS: The use of structured rounding tools potentially mitigates disproportionate time allocation and communication breakdowns during rounds, with the more structured HAND-IT, almost completely eliminating such effects. These results have potential implications for planning, prioritization, and training for time management during MDRs.

Applying the New Institute for Healthcare Improvement Inpatient Waste Tool to Identify "Waste" in the Intensive Care Unit.

Healthcare waste-the inappropriate use of healthcare resources that provides no benefit to patients yet contributes to cost and even harm-is a potentially significant contributor to high healthcare costs. This project aimed to apply a new locally modified Institute for Healthcare Improvement (IHI)-developed waste identification tool to measure the prevalence of and reason for the inappropriate use of intensive care unit (ICU) beds, one type of potential waste. Unnecessary days (i.e., waste) and their causes in a 16-bed "closed" medical ICU (MICU) and a 10-bed "semi-closed" transplant surgical ICU (TSICU) were identified by physicians over a 3-month period. Data on 513 patients admitted to both ICUs for a total of 1,631 patient-days demonstrated that 15% of MICU days and 25.8% of TSICU days were unnecessary. Although causes of waste in each ICU differed, delays in transfer of patients out of the ICU, end-of-life decision-making, and delays in procedures were among the commonest. Determination of waste also varied among physicians, ranging from 4.5% to 27.7% in the MICU and 0%-37.5% in the TSICU. This study found that the IHI waste tool can be effectively used to identify waste in the ICU, which is common and varies based on the ICU type and physician perceptions.

Characterizing the structure and content of nurse handoffs: A Sequential Conversational Analysis approach.

Effective communication during nurse handoffs is instrumental in ensuring safe and quality patient care. Much of the prior research on nurse handoffs has utilized retrospective methods such as interviews, surveys and questionnaires. While extremely useful, an in-depth understanding of the structure and content of conversations, and the inherent relationships within the content is paramount to designing effective nurse handoff interventions. In this paper, we present a methodological framework-Sequential Conversational Analysis (SCA)-a mixed-method approach that integrates qualitative conversational analysis with quantitative sequential pattern analysis. We describe the SCA approach and provide a detailed example as a proof of concept of its use for the analysis of nurse handoff communication in a medical intensive care unit. This novel approach allows us to characterize the conversational structure, clinical content, disruptions in the conversation, and the inherently phasic nature of nurse handoff communication. The characterization of communication patterns highlights the relationships underlying the verbal content of nurse handoffs with specific emphasis on: the interactive nature of conversation, relevance of role-based (incoming, outgoing) communication requirements, clinical content focus on critical patient-related events, and discussion of pending patient management tasks. We also discuss the applicability of the SCA approach as a method for providing in-depth understanding of the dynamics of communication in other settings and domains.

What CPR means to surrogate decision makers of ICU patients.

AIM OF THE STUDY: The decision to accept or decline cardiopulmonary resuscitation (CPR) by surrogate decision makers on behalf of a family member is a common and important component of end-of-life decision-making in the ICU. While many determinants influence this decision, surrogates' understanding of CPR may be a major guiding factor. However, little is known about surrogates' knowledge and perceptions of CPR during the periods of time when their family member is critically ill. We conducted this study to explore surrogates' understanding of some basic concepts of CPR. METHODS: This is a descriptive, survey-based exploratory study of understanding of CPR concepts and outcomes conducted in a single-center medical ICU at a tertiary academic hospital in the United States. Study subjects were surrogate decision-makers of critically ill ICU patients who participated in an interview-format survey within 24h of the patient's ICU admission. RESULTS: Of 97 eligible subjects (surrogates), 50 were enrolled in this study and represented a wide spectrum of demographics. All subjects had heard of CPR. The main source of information about CPR was a course. While 46% identified cardiac arrest as a main indication for CPR, only 8% identified at least 2 of the 3 main components of CPR. The majority (72%) believed survival after CPR was ≥75%. Forty-two percent of surrogates had spoken to the patient about CPR prior to coming to the hospital, and 57% had spoken to the physician during this hospitalization. Twenty-six percent changed their decision on CPR during the ICU stay. CONCLUSION: There is a wide variation in surrogates' understanding and knowledge of CPR concepts and outcomes.

Ventilator-associated events prevention, learning lessons from the past: A systematic review.

BACKGROUND: Preventing Ventilator-associated events (VAE) is a major challenge. Strictly monitoring for ventilator-associated pneumonia (VAP) is not sufficient to ensure positive outcomes. Therefore, the surveillance definition was updated and a change to the broader VAE was advocated. OBJECTIVE: This paper summarizes the scientific efforts assessing VAP preventive bundles and the recent transition in surveillance methods. METHODS: We conducted a systematic review to identify lessons from past clinical studies assessing VAP prevention bundles. We then performed a thorough literature review on the recent VAE surveillance algorithm, highlighting its advantages and limitations. CONCLUSION: VAP prevention bundles have historically proven their efficacy and the introduction of the new VAE definition aimed at refining and objectivizing surveillance methods. Randomized controlled trials remain vital to determine the effect of VAE prevention on patient outcomes. We recommend expanding beyond limited VAP prevention strategies towards VAE prevention bundles.

Low Testosterone Levels are Frequent in Patients with Acute Respiratory Failure and are Associated with Poor Outcomes.

OBJECTIVE: Low testosterone level is a common finding in critically ill patients with trauma, shock, and sepsis. However, its prevalence and outcomes in patients with primary acute respiratory failure is unknown; low testosterone could contribute to respiratory muscle weakness and further compromise ventilation in these patients. METHODS: We aimed to determine the prevalence, severity, and effects of hypotestosteronemia in patients with acute respiratory failure in a 16-bed single academic center medical intensive care unit (ICU). We studied 30 men who required mechanical ventilation for ≥24 hours for a primary diagnosis of acute respiratory failure. Blood samples were drawn on ICU day 1 and day 3 to measure serum levels of total and free testosterone. RESULTS: Hypotestosteronemia (level below the lower reference limit) was present on day 1 in 93.1% (total testosterone) and 76.7% (free testosterone) of patients and on day 3 in 94.4% (total testosterone) and 100% (free testosterone) of patients. Sex hormone-binding globulin, dehydroepiandrosterone sulfate, follicle-stimulating hormone, luteinizing hormone, and thyroid function levels were all within stated reference ranges. Total and free testosterone levels correlated inversely with ventilator days and ICU length of stay. CONCLUSION: Hypotestosteronemia is common in mechanically ventilated patients with primary acute respiratory failure and may contribute to longer ICU stay. Further studies are needed to determine the effect of testosterone replacement on short- and long-term outcomes in these patients.

Defining the practice of "no escalation of care" in the ICU.

OBJECTIVE: Withdrawal or withholding of life-sustaining therapies precedes most deaths in the modern ICU. As goals of care for critically ill patients change from curative to palliative, this transition often occurs abruptly, but a slower more staggered approach may also be used. One such approach is "no escalation of care", often the first step in this transition at the end-of-life. We aimed to determine the prevalence of no escalation of care designation for ICU decedents and identify which interventions are involved. DESIGN: We performed a retrospective medical record review of all patients who died over a two year period. Records with documentation of no escalation of care in physician orders or progress notes, or other instructions suggesting sequential or selective limitation of interventions were included. SETTING: Sixteen bed medical ICU at a single large academic hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of a total of 310 ICU decedents, 95 (30%) had a no escalation of care designation before death. Hemodialysis, vasopressors, and blood transfusions were the interventions more likely to be withheld. For ongoing therapies, hemodialysis, blood transfusions, and antibiotics were more likely to be withdrawn. Mechanical ventilation, hydration, and nutrition were less likely to be withheld or withdrawn. A minority had a palliative care consult (15%) or ethics consult (4%) while in the ICU. Time from no escalation of care designation to death averaged 0.8 days (range, 0-5 d). CONCLUSION: No escalation of care designation occurs in a significant proportion of ICU decedents shortly before death. Some interventions are more likely to be limited than others using a no escalation of care approach.

Comparative evaluation of the content and structure of communication using two handoff tools: implications for patient safety.

PURPOSE: Handoffs vary in their structure and content, raising concerns regarding standardization. We conducted a comparative evaluation of the nature and patterns of communication on 2 functionally similar but conceptually different handoff tools: Subjective, Objective, Assessment and Plan, based on a patient problem-based format, and Handoff Intervention Tool (HAND-IT), based on a body system-based format. METHOD: A nonrandomized pre-post prospective intervention study supported by audio recordings and observations of 82 resident handoffs was conducted in a medical intensive care unit. Qualitative analysis was complemented with exploratory sequential pattern analysis techniques to capture the characteristics and types of communication events (CEs) and breakdowns. RESULTS: Use of HAND-IT led to fewer communication breakdowns (F1,80 = 45.66: P < .0001), greater number of CEs (t40 = 4.56; P < .001), with more ideal CEs than Subjective, Objective, Assessment and Plan (t40 = 9.27; P < .001). In addition, the use of HAND-IT was characterized by more request-response CE transitions. CONCLUSION: The HAND-IT's body system-based structure afforded physicians the ability to better organize and comprehend patient information and led to an interactive and streamlined communication, with limited external input. Our results also emphasize the importance of information organization using a medical knowledge hierarchical format for fostering effective communication.

Understanding the nature of information seeking behavior in critical care: implications for the design of health information technology.

OBJECTIVE: Information in critical care environments is distributed across multiple sources, such as paper charts, electronic records, and support personnel. For decision-making tasks, physicians have to seek, gather, filter and organize information from various sources in a timely manner. The objective of this research is to characterize the nature of physicians' information seeking process, and the content and structure of clinical information retrieved during this process. METHOD: Eight medical intensive care unit physicians provided a verbal think-aloud as they performed a clinical diagnosis task. Verbal descriptions of physicians' activities, sources of information they used, time spent on each information source, and interactions with other clinicians were captured for analysis. The data were analyzed using qualitative and quantitative approaches. RESULTS: We found that the information seeking process was exploratory and iterative and driven by the contextual organization of information. While there was no significant differences between the overall time spent paper or electronic records, there was marginally greater relative information gain (i.e., more unique information retrieved per unit time) from electronic records (t(6)=1.89, p=0.1). Additionally, information retrieved from electronic records was at a higher level (i.e., observations and findings) in the knowledge structure than paper records, reflecting differences in the nature of knowledge utilization across resources. CONCLUSION: A process of local optimization drove the information seeking process: physicians utilized information that maximized their information gain even though it required significantly more cognitive effort. Implications for the design of health information technology solutions that seamlessly integrate information seeking activities within the workflow, such as enriching the clinical information space and supporting efficient clinical reasoning and decision-making, are discussed.

Falling through the cracks: information breakdowns in critical care handoff communication.

Handoffs have been recognized as a major healthcare challenge primarily due to the breakdowns in communication that occur during transitions in care. Consequently, they are characterized as being "remarkably haphazard". To investigate the information breakdowns in group handoff communication, we conducted a study at a large academic hospital in Texas. We used multifaceted qualitative methods such as observations, shadowing of care providers and their work activities, audio-recording of handoffs, and care provider interviews to examine the handoff communication workflow, with particular emphasis on investigating the sources of information breakdowns. Using a mixed inductive-deductive analysis approach, we identified two critical sources for information breakdowns - lack of standardization in handoff communication events and unsuccessful completion of pre-turnover coordination activities. We propose strategic solutions that can effectively help mitigate the handoff communication breakdowns.

High prevalence of chronic obstructive pulmonary disease among veterans in the urban midwest.

Although chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality within the Veterans Health care Administration, its prevalence and recognition are not known. We measured airflow limitation and diagnosed COPD at the Cincinnati Veteran's Administration Medical Center. Participants were 326 outpatients who performed spirometry and completed questionnaires. Health care-provider-diagnosis and self-diagnosis of COPD were compared with COPD defined by forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) < 0.7 (fixed ratio) and (FEV1/FVC)/lower limit of normal (LLN) < 1.0. COPD prevalence was 43% (95% confidence interval: 36.9, 48.1) by fixed ratio and 33% (95% confidence interval: 27.2, 36.8) by LLN. Eighteen percent of the patients had health care-provider-recorded and 23% had self-reported diagnoses of COPD. Positive predictive values for the diagnosis of COPD were 79% and 64% for healthcare providers versus 68% and 62% for patients; negative predictive values were 64% and 74% for healthcare providers versus 64% and 76% for patients (fixed ratio and LLN, respectively). COPD prevalence is higher among Cincinnati veterans than among general U.S. population. COPD is under-recognized by both health care providers and veterans.

Value of the PaO2:FiO2 ratio and Rapid Shallow Breathing Index in predicting successful extubation in hypoxemic respiratory failure.

PURPOSE: We sought to determine the predictive value of the PaO2:FiO2 ratio (PFR), both independently and in combination with the standard Rapid Shallow Breathing Index (RSBI), for successful extubations in patients with primary hypoxemic respiratory failure (HRF). MATERIALS AND METHODS: A retrospective chart review of 154 patients with HRF requiring mechanical ventilation for ≥24 hours was performed. The primary outcome was reintubation within 48 hours. RESULTS: 142 (92%) patients were successfully extubated. Pre-extubation PFR and RSBI values among reintubated and successfully extubated patients were similar. The areas under the curve of the receiver operating characteristic curves using RSBI and PFR were .5 and .62, respectively. A PFR < 200 or RSBI ≥ 70 when the PFR was ≥200 indicated a higher risk of reintubation, with .7 sensitivity and .56 specificity (area under the curve, .69), using a classification and regression tree model. CONCLUSIONS: Neither the PFR independently nor the PFR in combination with the RSBI in a classification and regression tree model accurately predicted successful extubation in patients with HRF.

Critical care education during internal medicine residency: a national survey.

BACKGROUND: Current training practices and teaching methods for critical care medicine education during internal medicine residency have not been well described. This study explored critical care medicine education practices and environments for internal medicine residents in the United States. METHODS: A web-based survey recruited Pulmonary and Critical Care Medicine fellowship program directors involved with internal medicine residency programs at academic institutions in the United States. RESULTS: Of 127 accredited Pulmonary and Critical Care Medicine programs in 2007, 63 (50%) responded. Demographics of the intensive care units varied widely in size (7-52 beds), monthly admissions (25-300 patients), and presence of a "night float" (22%) or an admissions "cap" (34%). All programs used bedside teaching, and the majority used informal sessions (91%) or didactic lectures (75%). More time was spent on resident teaching in larger (≥20 bed) medical intensive care units, on weekdays, in programs with a night-float system, and in programs that suspended residents' primary care clinic duties during their intensive care unit rotation. CONCLUSIONS: Although similar teaching methods were used within a wide range of training environments, there is no standardized approach to critical care medicine education for internal medicine residents. Some survey responses indicated a correlation with additional teaching time.

Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients.

PURPOSE: In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions. MATERIALS AND METHODS: Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes. RESULTS: Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P < .05), although changes in CPR decisions were similar in both groups (25% vs 18%, P = .5). CONCLUSIONS: Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR.

Elevated glucose in pleural effusion: an early clue to esophageal perforation.

Esophageal perforation is a rare cause of pleural effusions that carries with it a high mortality rate if diagnosis is delayed. The chemical characteristics of the pleural effusion include high amylase and low pH levels. However, these variables are nonspecific. We present a case of pleural effusion in a patient with markedly elevated glucose levels from recent cola ingestion as a specific clue to the diagnosis of esophageal perforation.

Management of pneumothorax in lymphangioleiomyomatosis: effects on recurrence and lung transplantation complications.

STUDY OBJECTIVES: Pneumothorax is a common complication of lymphangioleiomyomatosis (LAM), and the optimal approach to its treatment and prevention is unknown. Chemical or surgical pleurodesis are often required to prevent recurrence. However, their efficacy in LAM is unclear, and whether they contribute to perioperative complications during lung transplantation is uncertain. SETTING: The LAM Foundation database of registered patients. DESIGN: A questionnaire was sent to all registered patients who had at least one pneumothorax to determine rates and patterns of recurrence and efficacy of interventions. A second questionnaire was sent to registered LAM patients who received a lung transplant. PATIENTS OR PARTICIPANTS: Of 395 registered patients, 260 patients (66%) reported at least one pneumothorax during their lifetime, 193 of whom (74%) completed the questionnaire. Of the 85 lung transplant patients who were sent a separate questionnaire, 80 patients (94%) responded. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of the 193 respondents to the pneumothorax questionnaire, data on 676 episodes of pneumothorax were collected. Eighty-two percent (158 of 193 patients) had their first pneumothorax prior to a diagnosis of LAM. One hundred forty patients (73%) had at least one additional pneumothorax, either an ipsilateral recurrence (99 of 140 patients, 71%) or a contralateral pneumothorax (104 of 140 patients, 74%). Recurrence rates were 66% after conservative therapy, 27% after chemical pleurodesis, and 32% after surgery. In patients who had undergone lung transplantation, prior chemical or surgical pleurodesis was performed in 45 of 80 patients (56%). Fourteen of 80 patients (18%) reported pleural-related postoperative bleeding, 13 of whom (93%) had prior pleurodesis. CONCLUSIONS: Chemical pleurodesis or surgery are equally effective and better than conservative therapy in preventing recurrence of pneumothorax in LAM. Due to the high recurrence rate, either procedure should be considered for the initial pneumothorax in these patients. However, both contribute to increased perioperative bleeding following lung transplantation, with no effect on length of hospital stay.

Patient perspectives on management of pneumothorax in lymphangioleiomyomatosis.

STUDY OBJECTIVES: The American College of Chest Physicians Delphi Consensus Statement on management of spontaneous pneumothorax recommended pleurodesis after the first secondary spontaneous pneumothorax to prevent recurrence, and evaluation of patients' perspectives regarding pneumothorax treatment was identified as a future research priority. Patients with lymphangioleiomyomatosis (LAM) are an ideal population for performing these studies, since pneumothorax occurs and recurs more commonly in LAM than in any other chronic pulmonary disorder. STUDY DESIGN AND PARTICIPANTS: A 23-item questionnaire evaluating opinions of pneumothorax treatment was distributed to 615 patients in the LAM Foundation patient database, with a response rate of 52%. RESULTS: Of respondents, 69% (216 of 314 patients) reported a history of radiographically documented pneumothorax, and 181 patients (84%) reported at least one pleurodesis procedure. Neither a history of pneumothorax nor surgical management of pneumothorax affected reported oxygen use or perception of overall lung function, yet 41% thought that their pneumothorax had contributed to a decline in lung function. Few patients (12%) worried frequently about a pneumothorax developing, but one third made lifestyle modifications due to fear of pneumothorax. Extensive pain associated with chest tube placement and inadequate pain management throughout treatment for pneumothorax were frequent concerns. Only 25% of respondents thought that pleurodesis was appropriate for a first pneumothorax, while 60% favored pleurodesis for a second pneumothorax. Despite the apparent reluctance to undergo pleurodesis, most patients agreed that pleurodesis helps prevent pneumothorax recurrence. One third of patients believed that their physicians did not consider their preferences regarding pneumothorax management. CONCLUSIONS: LAM patients and physicians may have different views about the significance of pneumothorax, in that most patients appear to favor a conservative initial approach to pneumothorax management. In conjunction with appropriate pain management, a better understanding of patients' perspectives will facilitate cooperative decision making and may ultimately improve clinical outcomes in LAM related to pneumothorax.

Airway smooth muscle prostaglandin-EP1 receptors directly modulate beta2-adrenergic receptors within a unique heterodimeric complex.

Multiple and paradoxical effects of airway smooth muscle (ASM) 7-transmembrane-spanning receptors activated during asthma, or by treatment with bronchodilators such as beta(2)-adrenergic receptor (beta(2)AR) agonists, indicate extensive receptor crosstalk. We examined the signaling of the prostanoid-EP(1) receptor, since its endogenous agonist prostaglandin E(2) is abundant in the airway, but its functional implications are poorly defined. Activation of EP(1) failed to elicit ASM contraction in mouse trachea via this G(alphaq)-coupled receptor. However, EP(1) activation markedly reduced the bronchodilatory function of beta(2)AR agonist, but not forskolin, indicating an early pathway interaction. Activation of EP(1) reduced beta(2)AR-stimulated cAMP in ASM but did not promote or augment beta(2)AR phosphorylation or alter beta(2)AR trafficking. Bioluminescence resonant energy transfer showed EP(1) and beta(2)AR formed heterodimers, which were further modified by EP(1) agonist. In cell membrane [(35)S]GTPgammaS binding studies, the presence of the EP(1) component of the dimer uncoupled beta(2)AR from G(alphas), an effect accentuated by EP(1) agonist activation. Thus alone, EP(1) does not appear to have a significant direct effect on airway tone but acts as a modulator of the beta(2)AR, altering G(alphas) coupling via steric interactions imposed by the EP(1):beta(2)AR heterodimeric signaling complex and ultimately affecting beta(2)AR-mediated bronchial relaxation. This mechanism may contribute to beta-agonist resistance found in asthma.