Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care.

STUDY AIM: This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach. BACKGROUND: Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described. METHODS: We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER. The qualitative data analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the work process and identify work system elements. RESULTS: We identified 31 tasks characterized as decision making, patient education, communication, information, documentation, and scheduling tasks. Technological and organizational facilitators lacked in HHC compared to the hospitals. Person and organization elements in HHC had the most barriers but few facilitators. Additionally, we identified specific task barriers that could hinder sepsis information transfer from hospitals to HHC. CONCLUSION: This study explored the complex transition-in-care work processes for sepsis survivors going from hospitals to HHC. We identified barriers, facilitators, and critical areas for improvement to enable implementation and ensure safe care transitions. A key finding was the sepsis information transfer deficit, highlighting a critical issue for future study. APPLICATION: We recommend using the SEIPS framework to explore complex healthcare work processes before the implementation of evidence-based interventions.

Operation analysis of the tele-critical care service demonstrates value delivery, service adaptation over time, and distress among tele-providers.

Background: Our study addresses the gaps in knowledge of the characterizations of operations by remote tele-critical care medicine (tele-CCM) service providers interacting with the bedside team. The duration of engagements, the evolution of the tele-CCM service over time, and the distress during interactions with the bedside team have not been characterized systematically. These characteristics are critical for planning the deployment of teleICU services and preventing burnout among remote teleICU providers. Methods: REDCap self-reported activity logs collected engagement duration, triggers (emergency button, tele-CCM software platform, autonomous algorithm, asymmetrical communication platform, phone), expediency, nature (proactive rounding, predetermined task, response to medical needs), communication modes, and acceptance. Seven hospitals with 16 ICUs were overseen between 9/2020 and 9/2021 by teams consisting of telemedicine medical doctors (eMD), telemedicine registered nurses (eRN), and telemedicine respiratory therapists (eRT). Results: 39,915 total engagements were registered. eMDs had a significantly higher percentage of emergent and urgent engagements (31.9%) vs. eRN (9.8%) or eRT (1.7%). The average tele-CCM intervention took 16.1 ± 10.39 min for eMD, 18.1 ± 16.23 for eRN, and 8.2 ± 4.98 min for eRT, significantly varied between engagement, and expediency, hospitals, and ICUs types. During the observation period, there was a shift in intervention triggers with an increase in autonomous algorithmic ARDS detection concomitant with predominant utilization of asynchronous communication, phone engagements, and the tele-CCM module of electronic medical records at the expense of the share of proactive rounding. eRT communicated more frequently with bedside staff (% MD = 37.8%; % RN = 36.8, % RT = 49.0%) but mostly with other eRTs. In contrast, the eMD communicated with all ICU stakeholders while the eRN communicated chiefly with other RN and house staff at the patient's bedside. The rate of distress reported by tele-CCM staff was 2% among all interactions, with the entity hospital being the dominant factor. Conclusions: Delivery of tele-CCM services has to be tailored to the specific beneficiary of tele-CCM services to optimize care delivery and minimize distress. In addition, the duration of the average intervention must be considered while creating an efficient workflow.

Well-Being Among Respiratory Therapists in an Academic Medical Center During the COVID-19 Pandemic.

BACKGROUND: Recent studies have revealed high rates of burnout among respiratory therapists (RTs), which has implications for patient care and outcomes as well as for the health care workforce. We sought to better understand RT well-being during the COVID-19 pandemic. The purpose of this study was to determine rates and identify determinants of well-being, including burnout and professional fulfillment, among RTs in ICUs. METHODS: We conducted a mixed-methods study comprised of a survey administered quarterly from July 2020-May 2021 to critical-care health care professionals and semi-structured interviews from April-May 2021 with 10 ICU RTs within a single health center. We performed multivariable analyses to compare RT well-being to other professional groups and to evaluate changes in well-being over time. We analyzed qualitative interview data using thematic analysis, followed by mapping themes to the Maslow needs hierarchy. RESULTS: One hundred eight RTs responded to at least one quarterly survey. Eighty-two (75%) experienced burnout; 39 (36%) experienced professional fulfillment, and 62 (58%) reported symptoms of depression. Compared to clinicians of other professions in multivariable analyses, RTs were significantly more likely to experience burnout (odds ratio 2.32 [95% CI 1.41-3.81]) and depression (odds ratio 2.73 [95% CI 1.65-4.51]) and less likely to experience fulfillment (odds ratio 0.51 [95% CI 0.31-0.85]). We found that staffing challenges, safety concerns, workplace conflict, and lack of work-life balance led to burnout. Patient care, use of specialized skills, appreciation and a sense of community at work, and purpose fostered professional fulfillment. Themes identified were mapped to Maslow's hierarchy of needs; met needs led to professional fulfillment, and unmet needs led to burnout. CONCLUSIONS: ICU RTs experienced burnout during the pandemic at rates higher than other professions. To address RT needs, institutions should design and implement strategies to reduce burnout across all levels.

Certain Rooms in Intensive Care Units May Harbor Risk for Clostridioides difficile Infection.

Abstract Background: Clostridioides difficile infection (CDI) is a common and sometimes life-threatening illness. Patient-, care-, and room hygiene-specific factors are known to impact CDI genesis, but care provider training and room topography have not been explored. We sought to determine if care in specific intensive care unit (ICU) rooms asymmetrically harbored CDI cases. Patients and Methods: Surgical intensive care unit (SICU) patients developing CDI (July 2009 to June 2018) were identified and separated by service (green/gold). Each service cared for their respective 12 rooms, otherwise differing only in resident team composition (July 2009 to August 2017: green, anesthesia; gold, surgery; August 2017 to June 2018: mixed for both). Fixed/mobile room features and provider traffic in three room zones (far/middle/near in relation to the toilet) were compared between high-/low-incidence rooms using observation via telecritical care video cameras. Results: Seventy-four new CDI cases occurred in 7,834 consecutive SICU admissions. In period one, green CDI cases were almost double gold cases (39 vs. 21; p = 0.02) but were similar in period two in which trainee service allocation intermixed. High-incidence rooms had closer toilet-to-intravenous pole proximity than low-incidence rooms (7.7 + 1.8 feet vs. 3.9 + 1.5 feet; p = 0.02). High-incidence rooms consistently housed mobile objects (patient bed, table-on-wheels) farther away from the toilet. Although physician time spent in each zone was similar, nurses spending more than 15 minutes in-room more frequently stayed in the far/middle zones in high-incidence rooms. Conclusions: Distinct SICU room features relative to toilet location and bedside clinician behaviors interact to alter patient CDI acquisition risk. This suggests that CDI risk occurs as a structural aspect of ICU care, offering the potential to reduce patient risk through deliberate room redesign.

Improving Prone Positioning for Severe Acute Respiratory Distress Syndrome during the COVID-19 Pandemic. An Implementation-Mapping Approach.

Rationale: Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS), a feature of severe coronavirus disease 2019 (COVID-19). Despite this, most patients with ARDS do not receive this lifesaving therapy.Objectives: To identify determinants of prone-positioning use, to develop specific implementation strategies, and to incorporate strategies into an overarching response to the COVID-19 crisis.Methods: We used an implementation-mapping approach guided by implementation-science frameworks. We conducted semistructured interviews with 30 intensive care unit (ICU) clinicians who staffed 12 ICUs within the Penn Medicine Health System and the University of Michigan Medical Center. We performed thematic analysis using the Consolidated Framework for Implementation Research. We then conducted three focus groups with a task force of ICU leaders to develop an implementation menu, using the Expert Recommendations for Implementing Change framework. The implementation strategies were adapted as part of the Penn Medicine COVID-19 pandemic response.Results: We identified five broad themes of determinants of prone positioning, including knowledge, resources, alternative therapies, team culture, and patient factors, which collectively spanned all five Consolidated Framework for Implementation Research domains. The task force developed five specific implementation strategies, including educational outreach, learning collaborative, clinical protocol, prone-positioning team, and automated alerting, elements of which were rapidly implemented at Penn Medicine.Conclusions: We identified five broad themes of determinants of evidence-based use of prone positioning for severe ARDS and several specific strategies to address these themes. These strategies may be feasible for rapid implementation to increase use of prone positioning for severe ARDS with COVID-19.

Characteristics, Outcomes, and Trends of Patients With COVID-19-Related Critical Illness at a Learning Health System in the United States.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to surge in the United States and globally. OBJECTIVE: To describe the epidemiology of COVID-19-related critical illness, including trends in outcomes and care delivery. DESIGN: Single-health system, multihospital retrospective cohort study. SETTING: 5 hospitals within the University of Pennsylvania Health System. PATIENTS: Adults with COVID-19-related critical illness who were admitted to an intensive care unit (ICU) with acute respiratory failure or shock during the initial surge of the pandemic. MEASUREMENTS: The primary exposure for outcomes and care delivery trend analyses was longitudinal time during the pandemic. The primary outcome was all-cause 28-day in-hospital mortality. Secondary outcomes were all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions. RESULTS: Among 468 patients with COVID-19-related critical illness, 319 (68.2%) were treated with MV and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (interquartile range [IQR], 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change. LIMITATIONS: Single-health system study; use of, or highly dynamic trends in, other clinical interventions were not evaluated, nor were complications. CONCLUSION: Among patients with COVID-19-related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. Further studies are necessary to confirm this result and to investigate causal mechanisms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Evaluating Pain, Opioids, and Delirium in Critically Ill Older Adults.

Untreated pain and pain management with opioids are independent precipitating factors for delirium. This retrospective study evaluated the relationships among pain severity, its management with opioids, and the onset of delirium in older adult patients admitted to the surgical intensive care unit (SICU). Consecutive patients aged 65 or greater admitted to the SICU over a 5-month period were examined (n = 172). When assessed using a multivariable general estimating equation model, opioids (chi-square [χ2], 12.34, p = .0004), but not pain (χ2, 3.31, p = .0688) were significant in predicting next-day delirium status. Controlling for pain, patients exposed to opioids were 2.5 times more likely to develop delirium than patients not exposed (95% Confidence Interval: 1.44-4.36). Our data shows that opioid administration predicted the onset of next-day delirium. In an effort to prevent delirium, future research should focus on opioid-sparing pain management approaches to mitigate pain and delirium.

Benchmarking Critical Care Well-Being: Before and After the Coronavirus Disease 2019 Pandemic.

OBJECTIVES: Examine well-being, measured as burnout and professional fulfillment, across critical care healthcare professionals, ICUs, and hospitals within a health system; examine the impact of the coronavirus disease 2019 pandemic. DESIGN: To complement a longitudinal survey administered to medical critical care physicians at the end of an ICU rotation, which began in May 2018, we conducted a cross-sectional survey among critical care professionals across four hospitals in December 2018 to January 2019. We report the results of the cross-sectional survey and, to examine the impact of the coronavirus disease 2019 pandemic, the longitudinal survey results from July 2019 to May 2020. SETTING: Academic medical center. SUBJECTS: Four-hundred eighty-one critical care professionals, including 353 critical care nurses, 58 advanced practice providers, 57 physicians, and 13 pharmacists, participated in the cross-sectional survey; 15 medical critical care physicians participated in the longitudinal survey through the coronavirus disease 2019 pandemic. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Burnout was present in 50% of ICU clinicians, ranging from 42% for critical care physicians to 55% for advanced practice providers. Professional fulfillment was less common at 37%, with significant variability across provider (p = 0.04), with a low of 23% among critical care pharmacists and a high of 53% among physicians. Well-being varied significantly at the hospital and ICU level. Workload and job demand were identified as drivers of burnout and meaning in work, culture and values of work community, control and flexibility, and social support and community at work were each identified as drivers of well-being. Between July 2019 and March 2020, burnout and professional fulfillment were present in 35% (15/43) and 58% (25/43) of medical critical care physician responses, respectively. In comparison, during the coronavirus disease 2019 pandemic, burnout and professional fulfillment were present in 57% (12/21) and 38% (8/21), respectively. CONCLUSIONS: Burnout was common across roles, yet differed across ICUs and hospitals. Professional fulfillment varied by provider role. We identified potentially modifiable factors related to clinician well-being that can inform organizational strategies at the ICU and hospital level. Longitudinal studies, designed to assess the long-term impact of the coronavirus disease 2019 pandemic on the well-being of the critical care workforce, are urgently needed.

Evaluating delirium outcomes among older adults in the surgical intensive care unit.

BACKGROUND: Delirium is prevalent in hospitalized older adults. Little is known about delirium among older adults admitted to the surgical intensive care unit (SICU). OBJECTIVES: The purpose of this study was to describe the incidence of delirium, length of stay, 30-day readmission and mortality rates experienced by older adults in the SICU before and after a nurse-driven protocol for delirium-informed care. METHODS: This study employed a retrospective observational cohort design. Consecutive patients 65 years or older admitted to the SICU over six-month periods were compared before (n = 101) and following (n = 172) a nurse-driven protocol for delirium-informed care. Patient-level outcomes included incidence delirium, SICU and hospital length of stay, 30-day readmission and mortality rates. All measures were collected using medical record review. RESULTS: In the pre- and post-intervention cohorts, 37% (37/101) and 33% (56/172) of patients screened positive for delirium, respectively. Following implementation of the delirium-informed care intervention, the number of days where no CAM-ICU assessment was performed significantly decreased (Pre 1.1 ± 1.4; Post 0.45 ± 0.65; p <0.001) and the number of negative assessments significantly increased (Pre 2.45 ± 1.66; Post 2.94 ± 1.69; p < 0.0178), indicating that nurses post-intervention were more consistently assessing for delirium. CONCLUSIONS: This study failed to show improvements in patient outcomes (SICU and hospital length of stay, 30-day readmission and mortality rates), before and following a delirium-informed care intervention. However, positive trends in the data suggest that delirium-informed care has the potential to increase rates of assessment and delirium identification, thereby providing the foundation for reducing the consequences of delirium and improve patient-level outcomes. Further better controlled prospective work is needed to validate this intervention.

The Distinguished Nurse Clinician Academy: An Innovative Recognition Program for Frontline Clinicians.

The complexity and growth of healthcare systems provide nurse leaders an opportunity to recognize and facilitate professional development for experienced frontline clinicians and to create formal structures that give expert direct care nurses a stronger voice. The purpose of this article is to describe how one health system developed and implemented an innovative Distinguished Nurse Clinician Academy. This elite academy demonstrates the longitudinal impact of a health systems' Magnet culture.

A Partially Structured Postoperative Handoff Protocol Improves Communication in 2 Mixed Surgical Intensive Care Units: Findings From the Handoffs and Transitions in Critical Care (HATRICC) Prospective Cohort Study.

OBJECTIVE: To assess the effectiveness of standardizing operating room (OR) to intensive care unit (ICU) handoffs in a mixed surgical population. SUMMARY OF BACKGROUND DATA: Standardizing OR to ICU handoffs improves information transfer after cardiac surgery, but there is limited evidence in other surgical contexts. METHODS: This prospective interventional cohort study (NCT02267174) was conducted in 2 surgical ICUs in 2 affiliated hospitals. From 2014 to 2016, we developed, implemented, and assessed the effectiveness of a new standardized handoff protocol requiring bedside clinician communication using an information template. The primary study outcome was number of information omissions out of 13 possible topics, recorded by trained observers. Data were analyzed using descriptive statistics, bivariate analyses, and multivariable regression. RESULTS: We observed 165 patient transfers (68 pre-, 97 postintervention). Before standardization, observed handoffs had a mean 4.7 ±â€Š2.9 information omissions each. After standardization, information omissions decreased 21.3% to 3.7 ±â€Š1.9 (P = 0.023). In a pre-specified subanalysis, information omissions for new ICU patients decreased 36.2% from 4.7 ±â€Š3.1 to 3.0 ±â€Š1.6 (P = 0.008, interaction term P = 0.008). The decrement in information omissions was linearly associated with the number of protocol steps followed (P < 0.001). After controlling for patient stability, the intervention was still associated with reduced omissions. Handoff duration increased after standardization from 4.1 ±â€Š3.3 to 8.0 ±â€Š3.9 minutes (P < 0.001). ICU mortality and length of stay did not change postimplementation. CONCLUSION: Standardizing OR to ICU handoffs significantly improved information exchange in 2 mixed surgical ICUs, with a concomitant increase in handoff duration. Additional research is needed to identify barriers to and facilitators of handoff protocol adherence.

Pain, Agitation, and Delirium Guidelines: Interprofessional Perspectives to Translate the Evidence.

BACKGROUND: Societal guidelines exist for the management of pain, agitation, and delirium (PAD) in critically ill patients. This contemporary practice aims for a more awake and interactive patient. Institutions are challenged to translate the interrelated multivariable concepts of PAD into daily clinical practice and to demonstrate improvement in quality outcomes. An interdisciplinary goal-directed approach shows outcomes in high-acuity surgical critical care during the early stages of implementation. METHODS: This study was a prospective preintervention and postintervention design. A formal PAD clinical practice guideline targeting standardized assessment and "light" levels of sedation was instituted. All mechanically ventilated patients admitted to a 24-bed surgical intensive care unit (ICU) at an academic medical center during a 6-month period were included (3 months before and 3 months after implementation). Sedation and agitation were measured using the Richmond Agitation Sedation Scale (RASS), pain measured using a Behavioral or Numeric Pain Scale (NPS/BPS), and delirium using the Confusion Assessment Method for the Intensive Care Unit. Total ventilator days with exposure to continuous opioid or sedative infusions and total ICU days where the patient received a physical activity session exercising out of bed were recorded. RESULTS: There were 106 patients (54 at preintervention and 52 at postintervention). Mean percentage of RASS scores between 0 to -1 increased from 38% to 50% postintervention (P < .02). Mean percentage of NPS/BPS scores within the goal range (<5 for BPS and <3 for NPS) remained stable, 86% to 83% (P = .16). There was a decrease in use of continuous narcotic infusions for mechanically ventilated patients. This was reported as mean percentage of total ventilator days with a continuous opioid infusing: 65% before implementation versus 47% after implementation (P < .01). Mean percentage of ICU days with physical activity sessions increased from 24% to 41% (P < .001). Overall mean ventilator-free days and ICU length of stay were 5.4 to 4.5 days (P = .29) and 11.75 to 9.5 days (P = .20), respectively. CONCLUSION: Measureable patient outcomes are achievable in the early stages of PAD guideline initiatives and can inform future systems-level organizational change. Pain, agitation, and delirium assessment tools form the foundation for clinical implementation and evaluation. High-acuity surgical critical care patients can achieve more time at goal RASS, decreased ventilator days, and less exposure to continuous opioid infusions, all while maintaining stable analgesia.