Intraoperative Ventilator Management of the Critically Ill Patient.

Strategies for the intraoperative ventilator management of the critically ill patient focus on parameters used for lung protective ventilation with acute respiratory distress syndrome, preventing or limiting the deleterious effects of mechanical ventilation, and optimizing anesthetic and surgical conditions to limit postoperative pulmonary complications for patients at risk. Patient conditions such as obesity, sepsis, the need for laparoscopic surgery, or one-lung ventilation may benefit from intraoperative lung protective ventilation strategies. Anesthesiologists can use risk evaluation and prediction tools, monitor advanced physiologic targets, and incorporate new innovative monitoring techniques to develop an individualized approach for patients.

Opportunities and challenges to enhance the value and uptake of Chief Nursing Informatics Officer (CNIO) Roles in Canada: A Qualitative Study.

Clinician informatics leadership has been identified as an essential component of addressing the 'implementation to benefits realization gap' that exists for many digital health technologies. Chief Medical Informatics Officers (CMIOs), and Chief Nursing Informatics Officers (CNIOs) are well-positioned to ensure the success of these initiatives. However, while the CMIO role is fairly well-established in Canada, there is limited uptake of CNIO roles in the country. The main objective of this work is to build on the current progress of the CMIO role and explore how the CNIO role can be best positioned for uptake and value across healthcare organizations in Canada. A qualitative study was conducted. Ten clinician leaders in CMIO, CNIO, and related roles in Canada were interviewed about the value of these roles and strategies for supporting the uptake of the role. This study provides the foundation for future initiatives for supporting and showcasing the value of the CNIO in a digitally enabled healthcare organization.

Supporting the Development of Informatics Competencies Among Senior Nurse Leaders in Canada.

This poster will provide an overview of the various initiatives completed to support the development of informatics competencies among senior nurse leaders in Canada. These initiatives have included a literature review to uncover competencies of relevance to the Canadian context, and a Delphi study to achieve consensus on the competencies for Canada. Current and future plans will be discussed to translate these competencies into practice among senior nurse leaders.

Digital and informatics competencies: Requirements for nursing leaders in Canada.

The use of health information technologies continues to grow, especially with the increase in virtual care in response to COVID-19. As the largest health professional group in Canada, nurses are key stakeholders and their active engagement is essential for the meaningful adoption and use of digital health technologies to support patient care. Nurse leaders in particular are uniquely positioned to inform key technology decisions; therefore, enhancing their informatics capacity is paramount to the success of digital health initiatives and investments. The purpose of this commentary is to reflect on current projects relevant to the development of informatics competencies for nurse leaders in the Canadian context and offer our perspectives on ways to enhance current and future nurse leaders' readiness for participation in digital health initiatives. Addressing the digital health knowledge and abilities of nurse leaders will improve their capacity to champion and lead transformative health system changes through digital innovation.

Academic achievement and gender among adult critical care program directors.

PURPOSE: Accreditation Council for Graduate Medical Education (ACGME) program director (PD) qualifications includes scholarly activity with demonstrated academic productivity and dissemination. Our hypothesis: academic productivity among adult critical care medicine (CCM) fellowship PDs is affected by gender with women having lower productivity. MATERIALS AND METHODS: PDs in 39 institutions with CCM fellowships in anesthesiology, surgery, and pulmonary medicine were analyzed using data from ACGME website, PubMed, and NIH Research Portfolio Online Reporting Tools. Primary outcomes were total publications and h-index. Secondary outcomes included NIH funding and past five year publications. Independent variables and covariates included gender, academic rank, year appointed as program director, years certified in CCM, and specialty. RESULTS: PDs who were women had fewer total publications (median: 13 vs: 20, p = 0.030), past 5 years publications (median: 6 vs median: 9; p = 0.025), and less NIH funding (12% vs 32%; p = 0.046) compared to men. In exploratory analyses stratified by rank, assistant professor ranked women had fewer total (p = 0.027) and recent publications (p = 0.031) compared to men. CONCLUSIONS: Women who were PDs had fewer publications and less NIH funding compared to men with differences in publications more prominent in early career faculty.

Adapting and validating informatics competencies for senior nurse leaders in the Canadian context: Results of a Delphi study.

BACKGROUND: Nurse leaders in senior leadership positions in various parts of the world can play an important role in the acquisition, implementation and use of health information technologies. To date, international research related to nurse leader informatics competencies has been carried out in specific healthcare delivery contexts with very specific health information technology environments. In this body of literature, the definition of a 'nurse leader' has not been clearly defined. As a result, it is challenging for senior nurse leaders in leadership and management positions in other countries to apply this research to their unique contexts. PURPOSE: The objective of this study was to obtain consensus on the informatics competencies of priority to senior Canadian nurse leaders. The goal of completing this work was to adapt and validate a set of nurse leader informatics competencies to be endorsed and supported nationally. METHODS: This study used a modified Delphi technique with a panel of nurse leaders with significant informatics knowledge from across Canada. Three rounds of information gathering were completed electronically. In Round 1, participants were provided a series of 26 potential competency statements obtained from a review of the literature; they were asked to comment on the clarity and wording of each statement. Two statements were eliminated after Round 1 due to redundancy. In Rounds 2 and 3, participants rated the remaining competency statements on a 7-point Likert scale for relative priority to nurse leaders. RESULTS: A total of 25, 24 and 23 participants completed the survey in Rounds 1, 2 and 3 respectively. Consensus was achieved at the end of Round 3 with the inclusion of 24 competency statements. All of the statements had a mean of 5 or greater on a 7-point Likert scale (1=low priority and 7=high priority). CONCLUSIONS: The study participants agreed upon 24 informatics competency statements of priority to Canadian nurse leaders. These competencies will be presented to senior national nursing leaders and nursing informatics organizations for endorsement. Inspired by work completed in the United States, the authors plan to develop a self-assessment instrument for use by Canadian nurse leaders using the identified competency statements. Future anticipated work includes identifying and creating resources for nurse leaders to develop these important informatics competencies.

End-of-life discussions: Who's doing the talking?

PURPOSE: To determine, in a tertiary academic medical center, the reported frequency of end-of-life discussions among nurses and the influence of demographic factors on these discussions. METHODS: Survey of nurses on frequency of end-of-life discussions in two urban academic medical centers. Chi-square tests were used to separately assess the relationship between age, gender, specialty, and experience with responses to the question, "Do you regularly talk with your patients about end-of-life wishes?" RESULTS: Overall, more than one-third of respondents reported rarely or never discussing end-of-life wishes with their patients. Only specialty expertise (p<0.001) was statistically significantly associated with discussing end-of-life issues with patients. Over half of nurses specializing in critical care responded that they have these discussion "always" or "most of the time." However, for the specialties of surgery (59%) and anesthesiology (56%), the majority of respondents reported rarely or never having end-of-life discussions with patients. CONCLUSIONS: In a survey conducted in two tertiary care institutions, more than one-third of nurses from all disciplines responded that they never or almost never discuss end-of-life issues with their patients. Specialty influenced the likelihood of discussing end-of-life issues with patients.

Managing the Complex Issues of Pediatric Nonaccidental Trauma: A Simulation-Based Case of a Critically Injured Child.

INTRODUCTION: Trainees generally have insufficient training in managing critically ill and injured pediatric patients due to limited exposure to such patients. Patient simulation experiences allow trainees to learn management skills needed in such a crisis. Herein, we describe a case regarding a critically injured pediatric patient. This case requires trainees to use teamwork skills, medical knowledge, and technical skills to manage the patient. METHODS: We developed a team-based simulation regarding the resuscitation of a critically injured child-a toddler with multiple injuries, all requiring emergent care. The case was developed for senior medical students and residents and can be completed in a single 1-hour session, including a debriefing period. We also address psychosocial issues of managing a critically injured child by having the mother and her boyfriend present for part of the case. The team must address the underlying issue of suspected nonaccidental trauma while managing a medical resuscitation. RESULTS: We have performed this scenario with a cohort of 100 trainees. Through direct observations, all teams have been able to manage the patient successfully. The average response to the effectiveness of the case in terms of developing pediatric resuscitation skills was very positive, with scores of 6.7 on a scale of 1 to 7. DISCUSSION: Medical simulation has been demonstrated to be a valuable tool for assessing the knowledge and skills of trainees. This pediatric simulation improved learners' general understanding of managing a pediatric resuscitation. Accordingly, this case has been incorporated as part of resident and medical student training.

Hyperkalemic Arrest: Developing Team Cognition.

INTRODUCTION: Critical events are frequently managed by individuals with different skill sets, funds of knowledge, and experiences who form ad hoc teams on a daily basis without any previous practice together. Such groups' spontaneity of formation puts a premium on individuals' ability to understand team cognition and work together. Team cognition can be thought of as an analogue of individual cognition and is revealed during functional interactions of team members working interdependently on a shared goal. This simulation helps trainees develop and practice team-training skills in order to better form ad hoc teams and manage critical events. METHODS: This simulation can be applied to senior medical students and residents and focuses on the management of an accidental administration of potassium leading to hyperkalemic arrest. The simulation takes 10 minutes to complete and, when coupled with a debriefing session, can be accomplished in under 45 minutes. RESULTS: Twenty-two trainees, consisting of five teams of four to five residents, participated in this simulation. Each team showed varying levels of team cognition, and most successfully managed the hyperkalemic arrest; both of these points were reviewed at length during the debriefing. The trainees gave the simulation high ratings in terms of its effectiveness for team training, with a score of 6.7 on a scale of 1-7. DISCUSSION: Medical simulations have been very productive in providing learners with opportunities to manage critical events. With the exploding practice of interdisciplinary medicine, we believe simulation-based training should be implemented to develop team cognition and practice team training.

Contextualizing learning to improve care using collaborative communities of practices.

BACKGROUND: The use of interorganizational, collaborative approaches to build capacity in quality improvement (QI) in health care is showing promise as a useful model for scaling up and accelerating the implementation of interventions that bridge the "know-do" gap to improve clinical care and provider outcomes. Fundamental to a collaborative approach is interorganizational learning whereby organizations acquire, share, and combine knowledge with other organizations and have the opportunity to learn from their respective successes and challenges in improvement areas. This learning approach aims to create the conditions for collaborative, reflective, and innovative experiential systems that enable collective discussions regarding daily practice issues and finding solutions for improvement. METHODS: The concepts associated with interorganizational learning and deliberate learning activities within a collaborative 'Communities-of-practice'(CoP) approach formed the foundation of the of an interactive QI knowledge translation initiative entitled PERFORM KT. Nine teams participated including seven teams from two acute care hospitals, one from a long term care center, and one from a mental health sciences center. Six monthly CoP learning sessions were held and teams, with the support of an assigned mentor, implemented a QI project and monitored their results which were presented at an end of project symposium. 47 individuals participated in either a focus group or a personal interview. Interviews were transcribed and analyzed using an iterative content analysis. RESULTS: Four key themes emerged from the narrative dataset around experiences and perceptions associated with the PERFORM KT initiative: 1) being successful and taking it to other levels by being systematic, structured, and mentored; 2) taking it outside the comfort zone by being exposed to new concepts and learning together; 3) hearing feedback, exchanging stories, and getting new ideas; and 4) having a pragmatic and accommodating approach to apply new learnings in local contexts. CONCLUSIONS: Study findings offer insights into collaborative, inter-organizational CoP learning approaches to build QI capabilities amongst clinicians, staff, and managers. In particular, our study delineates the need to contextualize QI learning by using deliberate learning activities to balance systematic and structured approaches alongside pragmatic and accommodating approaches with expert mentors.

Academic Productivity of Accreditation Council for Graduate Medical Education-Accredited Critical Care Fellowship Program Directors.

OBJECTIVES: Academic productivity is an expectation for program directors of Accreditation Council for Graduate Medical Education-accredited subspecialty programs in critical care medicine. Within the adult critical care Accreditation Council for Graduate Medical Education-accredited programs, we hypothesized that program director length of time from subspecialty critical care certification would correlate positively with academic productivity, and primary field would impact academic productivity. DESIGN: This study received Institutional Review Board exemption from the University of Florida. Data were obtained from public websites on program directors from all institutions that had surgery, anesthesiology, and pulmonary Accreditation Council for Graduate Medical Education-accredited subspecialty critical care training programs during calendar year 2012. Information gathered included year of board certification and appointment to program director, academic rank, National Institutes of Health funding history, and PubMed citations. RESULTS: Specialty area was significantly associated with total (all types of publications) (p = 0.0002), recent (p < 0.0001), last author (p = 0.008), and original research publications (p < 0.0001), even after accounting for academic rank, years certified, and as a program director. These differences were most prominent in full professors, with surgery full professors having more total, recent, last author, and original research publications than full professors in the other critical care specialties. CONCLUSIONS: This study demonstrates that one's specialty area in critical care is an independent predictor of academic productivity, with surgery having the highest productivity. For some metrics, such as total and last author publications, surgery had more publications than both anesthesiology and pulmonary, whereas there was no difference between the latter groups. This suggests that observed differences in academic productivity vary by specialty.

The Case for Standardized Data in Nursing.

With the increased focus on quality and safety within the healthcare system, the collection, reporting and use of standardized data are essential to understanding the impact of clinicians practice on patient care. This article examines how the Canadian Health Outcomes for Better Information and Care (C-HOBIC) dataset can support clinical decision-making and facilitate improved sharing of information as patients transition between sectors of the healthcare system. If the benefits of electronic health records are to be fully realized, it is vital that information is collected in a standardized format to support point-of-care clinicians in decision-making, as well as for health system use.

Long-Term Outcomes for Different Forms of Stress Cardiomyopathy After Surgical Treatment for Subarachnoid Hemorrhage.

BACKGROUND: Stress-induced cardiomyopathy (SCM) after subarachnoid hemorrhage (SAH) includes predominant apical or basal regional left ventricular dysfunction (RLVD) with concomitant changes in electrocardiogram or increase in cardiac enzymes. We hypothesized that difference in outcome is associated with the type of RLVD after SAH. METHODS: We studied a single-center retrospective cohort of SAH patients hospitalized between 2000 and 2010 with follow-up until 2013. We classified patients who had an echocardiogram for clinically indicated reasons according to the predominate location of RLVD as classic SCM-apical form and variant SCM-basal form. A Cox proportional hazard model and logistic regression were used to estimate the risk for death and hospital complications associated with different RLVD after adjustment for propensity to undergo echocardiography given clinical characteristics on admission. RESULTS: Among 715 SAH patients, 28% (200/715) had an echocardiogram for clinical evidence of cardiac dysfunction during hospitalization, the most common being acute left ventricular dysfunction, suspected acute ischemic event, changes in electrocardiogram and cardiac enzymes, and arrhythmia. SCM was present in 59 patients (8% of all cohort and 30% of patients with echocardiogram, respectively) with similar distribution of SCM-basal (25/59) and SCM-apical forms (34/59). SAH patients who had an echocardiogram for clinically indicated reasons had a significantly decreased risk-adjusted long-term survival compared with those without an echocardiogram, regardless of the presence of RLVD. SCM-basal form was associated with cardiac complications (odds ratio, 6.1; 99% confidence interval, 1.8-20.2) and severe sepsis (odds ratio, 5.3; 99% confidence interval, 1.6-17.2). CONCLUSIONS: SAH patients with echocardiogram for a clinically indicated reason have a decreased long-term survival, regardless of the presence of RLVD. The association between severe sepsis and SCM-basal warrants future studies to determine their potential synergistic effect on left ventricular systolic dysfunction among SAH patients.

Nutrition and metabolic support for critically ill patients.

PURPOSE OF REVIEW: Acute critical illness increases the risk of malnutrition, are more obese, and have multiple comorbidities and frequent pre-existing nutritional deficits. There is a vast amount of research and literature being written on nutritional practices in the critically ill. We review and discuss herein the important nutrition literature over the past 12 months. RECENT FINDINGS: Sarcopenia, defined as loss of skeletal mass and strength, is associated with increased mortality and morbidity, particularly in elderly patients with trauma. Ultrasound is emerging as a noninvasive and promising method of measuring muscularity. Measuring gastric residuals and postpyloric feeding may not decrease rates of pneumonia in critically ill patients. Trophic and full feeding lead to similar long-term functional and cognitive outcomes in patients with acute respiratory distress syndrome. SUMMARY: Nutrition and metabolic support of critically ill patients is a complex and diverse topic. Nutritional measurements, requirements, and modes and routes of delivery are currently being studied to determine the best way to treat these complicated patients. We present just a few of the current controversial topics in this fascinating arena.

Leveraging data to transform nursing care: insights from nurse leaders.

A study was undertaken to gain insight into how nurse leaders are influencing the use of performance data to improve nursing care in hospitals. Two themes emerged: getting relevant, reliable, and timely data into the hands of nurses, and the leaders' ability to "connect the dots" in working with different stakeholders. Study findings may inform nurse leaders in their efforts to leverage data to transform nursing care.

The relationship among evidence-based practice and client dyspnea, pain, falls, and pressure ulcer outcomes in the community setting.

BACKGROUND: There are gaps in knowledge about the extent to which home care nurses' practice is based on best evidence and whether evidence-based practice impacts patient outcomes. AIM: The purpose of this study was to investigate the relationship between evidence-based practice and client pain, dyspnea, falls, and pressure ulcer outcomes in the home care setting. Evidence-based practice was defined as nursing interventions based on best practice guidelines. METHODS: The Nursing Role Effectiveness model was used to guide the selection of variables for investigation. Data were collected from administrative records on percent of visits made by Registered Nurses (RN), total number of nursing visits, and consistency of visits by principal nurse. Charts audits were used to collect data on nursing interventions and client outcomes. The sample consisted of 338 nurses from 13 home care offices and 939 de-identified client charts. Hierarchical generalized linear regression approaches were constructed to explore which variables explain variation in client outcomes. RESULTS: The study found documentation of nursing interventions based on best practice guidelines was positively associated with improvement in dyspnea, pain, falls, and pressure ulcer outcomes. Percent of visits made by an RN and consistency of visits by a principal nurse were not found to be associated with improved client outcomes, but the total number of nursing visits was. LINKING EVIDENCE TO ACTION: Implementation of best practice is associated with improved client outcomes in the home care setting. Future research needs to explore ways to more effectively foster the documentation of evidence-based practice interventions.

Evaluating nurses' use of HOBIC in home care.

Health Outcomes for Better Information and Care (HOBIC), a program funded by the Ontario Ministry of Health and Long-Term Care, introduces a collection of evidence-based clinical outcome measures reflective of nursing care. The authors report on an evaluation of the experiences of nurse early adopters of HOBIC in home care. The findings reveal challenges and nuances associated with the introduction of HOBIC and the use of supporting technologies in the delivery of home nursing care. Future implementation efforts should focus on optimizing the usability of technology and the usefulness of HOBIC in nursing practice. In addition, efforts need to be directed at supporting the full integration and use of HOBIC outcome data by nurses and management personnel to inform practice directions.