Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness.

AIM: Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation. DESIGN AND IMPLEMENTATION: We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including 'VITAL' (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, 'STOP' (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and 'STOP' (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme. RESULTS: The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001). CONCLUSION: The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Maximal expiratory pressure is associated with reinstitution of mechanical ventilation after successful unassisted breathing trials in tracheostomized patients with prolonged mechanical ventilation.

OBJECTIVE: Reinstitution of mechanical ventilation (MV) for tracheostomized patients after successful weaning may occur as the care setting changes from critical care to general care. We aimed to investigate the occurrence, consequence and associated factors of MV reinstitution. METHODS: We analyzed the clinical data and physiological measurements of tracheostomized patients with prolonged MV discharged from the weaning unit to general wards after successful weaning to compare between those with and without in-hospital MV reinstitution within 60 days. RESULTS: Of 454 patients successfully weaned, 116 (25.6%) reinstituted MV at general wards within 60 days; at hospital discharge, 42 (36.2%) of them were eventually liberated from MV, 51 (44.0%) remained MV dependent, and 33 (28.4%) died. Of the 338 patients without reinstitution within 60 days, only 3 (0.9%) were later reinstituted with MV before discharge (on day 67, 89 and 136 at general wards, respectively), and 322 (95.2%) were successfully weaned again at discharge, while 13 (3.8%) died. Patients with MV reinstitution had a significantly lower level of maximal expiratory pressure (PEmax) before unassisted breathing trial compared to those without reinstitution. Multivariable Cox regression analysis showed fever at RCC discharge (hazard ratio [HR] 14.00, 95% confidence interval [CI] 3.2-61.9) chronic obstructive pulmonary disease (HR 2.37, 95% CI 1.34-4.18), renal replacement therapy at the ICU (HR 2.29, 95% CI 1.50-3.49) and extubation failure before tracheostomy (HR 1.76, 95% CI 1.18-2.63) were associated with increased risks of reinstitution, while PEmax > 30 cmH2O (HR 0.51, 95% CI 0.35-0.76) was associated with a decreased risk of reinstitution. CONCLUSIONS: The reinstitution of MV at the general ward is significant, with poor outcomes. The PEmax measured before unassisted breathing trial was significantly associated with the risk of reinstituting MV at the general wards.

Quality gaps and priorities for improvement of healthcare service for patients with prolonged mechanical ventilation in the view of family.

BACKGROUND: Little is known about the gaps between expectation and the perception of service quality in the care setting of prolonged mechanical ventilation (MV). METHODS: We conducted this prospective study at the Respiratory Care Center (RCC) of a medical center from February 2017 to January 2018. Family members of the patients admitted to the RCC completed a questionnaire based on the SERVQUAL instrument in two sections - expectation and perception, consisting of 22 questions each in five dimensions. We analyzed the gaps between paired items, used important-performance analysis (IPA) to identify priority items for improvement, and performed multivariate logistic regression analysis. RESULTS: A total of 167 respondents participated in the survey. The average length of patient stay in the RCC was 19.4 days, and 70.7% were successfully liberated from MV. The overall mean SERVQUAL scores for the two sections were similar (4.50 ± 0.52 and 4.51 ± 0.54 for expectation and perception, respectively; p = 0.808). IPA identified four items, including one "tangible," one "reliability" and two "empathy" with an undesired expectation/perception gap indicating a priority for improvement. Multivariate logistic regression analysis showed that male respondents, patients older than 75 years, tracheostomy, and the need for physical training or dialysis were associated with an increased gap in these priority items. CONCLUSION: Gaps exist between expectation and perception in multiple dimensions of the quality of healthcare service in the care setting of prolonged MV, indicating unmet needs and priorities for improvement.