Patterns of interactions among ICU interprofessional teams: A prospective patient-shift-level survey approach.

BACKGROUND: The Awakening, Breathing Coordination, Delirium monitoring and Early mobility bundle (ABCDE) is associated with lower mortality for intensive care unit (ICU) patients. However, efforts to improve ABCDE are variably successful, possibly due to lack of clarity about who are the team members interacting when caring for each patient, each shift. Lack of patient shift-level information regarding who is interacting with whom limits the ability to tailor interventions to the specific ICU team to improve ABCDE. OBJECTIVE: Determine the number and types of individuals (i.e., clinicians and family members) interacting in the care of mechanically ventilated (MV) patients, as reported by the patients' assigned physician, nurse, and respiratory therapist (RT) each shift, using a network science lens. METHODS: We conducted a prospective, patient-shift-level survey in 2 medical ICUs. For each patient, we surveyed the assigned physician, nurse, and RT each day and night shift about who they interacted with when providing ABCDE for each patient-shift. We determined the number and types of interactions, reported by physicians, nurses, and RTs and day versus night shift. RESULTS: From 1558 surveys from 404 clinicians who cared for 169 patients over 166 shifts (65% response rate), clinicians reported interacting with 2.6 individuals each shift (physicians: 2.65, nurses: 3.33, RTs: 1.86); this was fewer on night shift compared to day shift (1.99 versus 3.02). Most frequent interactions were with the bedside nurse, attending, resident, intern, and RT; family member interactions were reported in less than 1 in 5 surveys (12.2% of physician surveys, 19.7% of nurse surveys, 4.9% of RT surveys). INTERPRETATION: Clinicians reported interacting with 3-4 clinicians each shift, and fewer on nights. Nurses interacted with the most clincians and family members. Interventions targeting shift-level teams, focusing on nurses and family members, may be a way to improve ABCDE delivery and ICU teamwork.

Addressing the Nursing Workforce Crisis Through Nurse-Physician Collaboration.

This Viewpoint explores root causes of the nurse staffing shortages in the US and proposes solutions that involve physicians.

Sources of Contraception Among Adolescents and Young Adults.

This cross-sectional study describes the nationwide pattern of contraception access by sociodemographic characteristics and health care settings among US youth aged 15 to 24 years.

Knowing your team in the intensive care unit: an ethnographic study on familiarity.

Effective interprofessional team function is integral to high-quality care in the intensive care unit (ICU). However, little is known about how familiarity develops among teams, which may be an important antecedent to effective team function and quality care. To examine team familiarity and how it impacts ICU team function and care, we conducted an ethnographic study in four ICUs (two medical ICUs, one mixed medical-surgical ICU, and one surgical ICU) in two community hospitals and one academic medical center. We conducted 57.5 h of observation, 26 shadowing experiences, and 26 interviews across the four ICUs sequentially. We used thematic analysis to examine familiarity among the team. We found that ICU team members become familiar with their team through interpersonal, relational interactions, which involved communication, time working together, social interactions, trust, and respect. Our findings underscore the relational aspect of effective teams and demonstrate that time working together, social interactions, communication, developing trust, and respect are pathways to familiarity and optimal team function. Leveraging unique and creative ways to enhance the relational aspects of ICU teams could be an area for future research and lead to improved ICU outcomes.

Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report.

In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.

Development and Evaluation of a Data-Driven, Interactive Workshop to Facilitate Communication and Teamwork in Ambulatory Medical Oncology Settings.

Background: While adverse events and toxicities related to cancer drug therapy in the ambulatory oncology setting are common and often rooted in communication challenges, few studies have examined the problems of communication or tested tools to improve communication in this unique, high-risk setting. Objective: To determine the feasibility and acceptability of a virtual interdisciplinary communication Workshop designed to strengthen communication across ambulatory oncology teams members. Methods: Surveys of patients and clinicians in one ambulatory oncology clinic were analyzed and informed the communication intervention: an interdisciplinary virtual Workshop. Workshop evaluation included an implementation survey measure and a structured debrief with Workshop attendees. Results: 87 patients and 56 clinicians participated in pre-workshop surveys that revealed patient satisfaction with timely care and information, yet a range of rating communication experiences with the clinical team, and clinicians perceiving a high amount of organizational safety, yet rated discussion of alternatives to normal work processes low. Survey results guided reflection and discussion within the Workshop. Six clinicians participated in the interactive Workshop. Feasibility and acceptability of the virtual Workshop were supported by formative and summative data, along with suggestions for improvement. Conclusions: The patient and clinician surveys coupled with an interactive virtual Workshop were feasible and acceptable. Implications for Practice: The Workshop identified opportunities for individual- and system-level improvements in clinical team communication. This promising strategy requires replication in larger, diverse practice samples. Foundational: Clinicians accepted an interactive workshop that incorporated clinic-specific data and communication strategies. The program is feasible and acceptable in ambulatory oncology settings.

Preparing nurse scientists for health services and policy research: Five-year outcomes of interprofessional postdoctoral training in the National Clinician Scholars Program.

BACKGROUND: The National Clinician Scholars Program (NCSP) is an interprofessional postdoctoral fellowship for physicians and nurses with a PhD. or DNP focused on health services research, policy, and leadership. PURPOSE: To evaluate 5-year outcomes of nurse postdoctoral scholars in the NCSP. METHODS: We describe the 5-year outcomes of nurse fellows and graduates from six NCSP sites (positions, number of peer-reviewed publications, citations, and h-index). CONCLUSION: There were 53 nurses in the sample (34 alumni, 19 fellows). Approximately half (47%, n = 16) of alumni had tenure-track faculty positions and had bibliometric performance indicators (such as h-indices) 2 to 4 times greater than those previously reported for assistant professors in nursing schools nationally. NCSP nurse scholars and alumni also had an impact on community partnerships, health equity, and health policy DISCUSSION: This study highlights the potential of interprofessional postdoctoral fellowships such as the NCSP to prepare nurse scientists for health care leadership roles.

Leveraging Population Health Datasets to Advance Maternal Health Research.

BACKGROUND: Maternal mortality is a public health crisis in the U.S., with no improvement in decades and worsening disparities during COVID-19. Social determinants of health (SDoH) shape risk for morbidity and mortality but maternal structural and SDoH are under-researched using population health data. To expand knowledge of those at risk for or who have experienced maternal morbidity and inform clinical, policy, and legislative action, creative use of and leveraging existing population health datasets is logical and needed. METHODS: We review a sample of population health datasets and highlight recommended changes to the datasets or data collection to better inform existing gaps in maternal health research. RESULTS: Across each of the datasets we found insufficient representation of pregnant and postpartum individuals and provide recommendations to enhance these datasets to inform maternal health research. CONCLUSIONS: Pregnant and postpartum individuals should be oversampled in population health data to facilitate rapid policy and program evaluation. Postpartum individuals should no longer be hidden within population health datasets. Individuals with pregnancies resulting in outcomes other than livebirth (e.g., abortion, stillbirth, miscarriage) should be included, or asked about these experiences.

SIGNIFICANCE: We review population health datasets and provide recommendations that would enable maternal health researchers to unlock the full potential of these datasets by exploring the influence of structural factors and SDoH on maternal health among under-researched groups.

Characteristics of Facilities With Early and Rapid Ustekinumab Adoption for Patients With Inflammatory Bowel Disease.

INTRODUCTION: To examine which facility characteristics, including teamwork, are associated with early or rapid inflammatory bowel disease-related ustekinumab adoption. METHODS: We examined the association between ustekinumab adoption and the characteristics of 130 Veterans Affairs facilities. RESULTS: Mean ustekinumab adoption increased by 3.9% from 2016 to 2018 and was higher in urban compared with rural facilities (ß = 0.03, P = 0.033) and among facilities with more teamwork (ß = 0.11, P = 0.041). Compared with nonearly adopters, early adopters were more likely be high-volume facilities (46% vs 19%, P = 0.001). DISCUSSION: Facility variation in medication adoption provides an opportunity for improving inflammatory bowel disease care through targeted dissemination strategies to improve medication uptake.

Extubation of Patients Receiving Vasopressor Infusions: Results of a Survey on Statewide Practices.

Current guidelines recommend extubation only if a patient is not receiving vasopressor therapy or is receiving minimal doses of vasopressors. However, recent data indicate that extubation of patients receiving higher vasopressor doses may be safe. This study was undertaken to examine practices regarding extubation of patients receiving vasopressor therapy reported by clinician respondents to a survey by the Michigan Health and Hospital Association Keystone Center. One-third of respondents indicated that they would extubate a patient receiving vasopressors, and one-quarter indicated that it depended on the agent used, but more than half reported that their unit did not have a vasopressor use protocol or they did not know whether it did. Practices regarding extubation of patients receiving vasopressor therapy differed significantly by unit type and by role as a direct care provider. These data indicate that patient and clinician factors may drive practice patterns. Additional research to inform guidelines and local protocols is warranted.

Understanding clinician connections to inform efforts to promote high-quality inflammatory bowel disease care.

BACKGROUND: Highly connected individuals disseminate information effectively within their social network. To apply this concept to inflammatory bowel disease (IBD) care and lay the foundation for network interventions to disseminate high-quality treatment, we assessed the need for improving the IBD practices of highly connected clinicians. We aimed to examine whether highly connected clinicians who treat IBD patients were more likely to provide high-quality treatment than less connected clinicians. METHODS: We used network analysis to examine connections among clinicians who shared patients with IBD in the Veterans Health Administration between 2015-2018. We created a network comprised of clinicians connected by shared patients. We quantified clinician connections using degree centrality (number of clinicians with whom a clinician shares patients), closeness centrality (reach via shared contacts to other clinicians), and betweenness centrality (degree to which a clinician connects clinicians not otherwise connected). Using weighted linear regression, we examined associations between each measure of connection and two IBD quality indicators: low prolonged steroids use, and high steroid-sparing therapy use. RESULTS: We identified 62,971 patients with IBD and linked them to 1,655 gastroenterologists and 7,852 primary care providers. Clinicians with more connections (degree) were more likely to exhibit high-quality treatment (less prolonged steroids beta -0.0268, 95%CI -0.0427, -0.0110, more steroid-sparing therapy beta 0.0967, 95%CI 0.0128, 0.1805). Clinicians who connect otherwise unconnected clinicians (betweenness) displayed more prolonged steroids use (beta 0.0003, 95%CI 0.0001, 0.0006). The presence of variation is more relevant than its magnitude. CONCLUSIONS: Clinicians with a high number of connections provided more high-quality IBD treatments than less connected clinicians, and may be well-positioned for interventions to disseminate high-quality IBD care. However, clinicians who connect clinicians who are otherwise unconnected are more likely to display low-quality IBD treatment. Efforts to improve their quality are needed prior to leveraging their position to disseminate high-quality care.

Addressing Compassion Fatigue in Trauma Emergency and Intensive Care Settings: A Pilot Study.

BACKGROUND: Emergency and intensive care health care professionals are experiencing exhaustion and helplessness, which may cause compassion fatigue. Unaddressed compassion fatigue impacts staff morale and patient safety. Structured debriefing sessions may reduce compassion fatigue by providing social support and increasing job satisfaction. OBJECTIVE: To investigate the feasibility of a 12-week pilot of structured debriefing sessions and its impact on compassion fatigue experienced by emergency and intensive care health care professionals after patient death. METHODS: In this 12-week pilot study (March 2021 to May 2021), we used a preintervention/postintervention design to determine the feasibility of structured debriefing among trauma health care professionals experiencing patient death in an urban, academic, 300-bed, Midwest, Level II trauma center. Compassion fatigue was measured using the Professional Quality of Life Measure survey. Univariate descriptive statistics, independent unpaired t tests, and χ2 tests examined the intervention impact. RESULTS: Fifty-six health care professionals participated in 20 debriefing sessions during the 12-week intervention: 37 (80%) registered nurses, 10 (5.6%) respiratory therapists, and 5 (11.2%) nursing assistants or emergency medical technicians. The debriefings covered nearly half of all patient deaths (38%). No significant differences were seen in burnout (M = 25.5, SD = 5.4, p = .47), secondary traumatic stress (M = 23.9, SD = 5.6, p = .99), or compassion satisfaction (M = 36.8, SD = 6.4, p = .61). CONCLUSIONS: Structured debriefings to address compassion fatigue among trauma health care professionals are feasible, but further research on effectiveness is needed. Administration-provided emotional support strategies may assist health care professionals in processing work-related stress.

Exploring the process of information sharing in an adult intensive care unit: an ethnographic study.

Information sharing, a component of patient and family engagement (PFE), is an important process that may contribute to intensive care unit (ICU) quality of care. Yet, virtually no studies explore how the process of information sharing unfolds in the ICU from the interprofessional team and family member perspectives. To better understand the process of information sharing, we conducted ethnographic fieldwork in a 20-bed medical ICU, focusing on behaviors and interactions of the interprofessional team and family members (May 2016 - October 2016). We completed 17.5 observation hours, 6 shadowing sessions, and 12 semi-structured interviews with 17 total participants. We used thematic content analysis and iterative inductive coding to identify three themes about the information sharing process: 1) family factors (health literacy and past experience with the ICU environment) influence information sharing; 2) clinicians strategies can support engagement in the process of information sharing (assessing families' need for information, understanding a families' hope, using rounds as an opportunity for information sharing); 3) the process of information sharing allows for trust building between families and the ICU team. Our findings suggest that information sharing is a crucial process that may serve as a catalyst for effective patient and family engagement in the ICU.

Actions Taken by US Hospitals to Prepare for Increased Demand for Intensive Care During the First Wave of COVID-19: A National Survey.

BACKGROUND: The COVID-19 pandemic placed considerable strain on critical care resources. How US hospitals responded to this crisis is unknown. RESEARCH QUESTION: What actions did US hospitals take to prepare for a potential surge in demand for critical care services in the context of the COVID-19 pandemic? STUDY DESIGN AND METHODS: From September to November 2020, the chief nursing officers of a representative sample of US hospitals were surveyed regarding organizational actions taken to increase or maintain critical care capacity during the COVID-19 pandemic. Weighted proportions of hospitals for each potential action were calculated to create estimates across the entire population of US hospitals, accounting for both the sampling strategy and nonresponse. Also examined was whether the types of actions taken varied according to the cumulative regional incidence of COVID-19 cases. RESULTS: Responses were received from 169 of 540 surveyed US hospitals (response rate, 31.3%). Almost all hospitals canceled or postponed elective surgeries (96.7%) and nonsurgical procedures (94.8%). Few hospitals created new medical units in areas not typically dedicated to health care (12.9%), and almost none adopted triage protocols (5.6%) or protocols to connect multiple patients to a single ventilator (4.8%). Actions to increase or preserve ICU staff, including use of ICU telemedicine, were highly variable, without any single dominant strategy. Hospitals experiencing a higher incidence of COVID-19 did not consistently take different actions compared with hospitals facing lower incidence. INTERPRETATION: Responses of hospitals to the mass need for critical care services due to the COVID-19 pandemic were highly variable. Most hospitals canceled procedures to preserve ICU capacity and scaled up ICU capacity using existing clinical space and staffing. Future research linking hospital response to patient outcomes can inform planning for additional surges of this pandemic or other events in the future.